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Student Attestation Form

Today's Date*
Date Format: MM slash DD slash YYYY
This will certify that I, and no one else, completed the Live Distance Education course known as:*
(Insert class title)
The course is approved for _______ hours of New York State continuing education credit.*
The course was completed on:*
Date Format: MM slash DD slash YYYY
Student Name*
First Last
Student Email*
Student Phone*
Student Mailing Address*
Street Address Address Line 2 City State ZIP Code
11-Digit License Registration Number:*
(Located on your DOS-issued Pocket Card)
Confirmation*
I certify under penalty of perjury and false swearing that I am the student who took the above course and that this typed signature has the same legal effect and can be enforced in the same way as a written signature.
Signature*
Type your first and last name