Fcb Accommodation Request Form (Page 2 of 2) in pdf

Fcb Accommodation Request Form Page 2

DOCUMENTATION OF DISABILITY RELATED NEEDS

If you have a disability/impairment (physical, mental, learning, psychological or other

hidden disability) that requires an accommodation in testing, please have this section

completed by an appropriate professional (education professional, doctor, psychologist,

etc.).

I have known ________________________________ since _____________ in my capacity as

(Test Applicant)

(Date)

a _______________________________________________________________________________

(professional title)

Describe nature of applicant’s disability: Give detailed description and explain the

extent to which the disability requires testing accommodations. Define precise limitations

imposed by the disability.

________________________________________________________________________________

I declare and affirm that the statements made are true, complete, and correct. I understand

that any false or misleading information may be cause for denial or loss of

certification/licensure.

__________________________________________________

_____________________

Signature

Date

Fcb Accommodation Request Form Page 2