Student Attestation Form

Today's Date*

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:*

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

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Student Attestation Form

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