Form Bah - Barber And Hairdresser Application - Alaska Department Of Community And Economic Development Page 7
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7CONFIDENTIAL
CONFIDENTIAL
State of Alaska
Department of Community and Economic Development
Division of Occupational Licensing
Board of Barbers and Hairdressers
333 Willoughby, 9th Floor, State Office Building
P.O. Box 110806, Juneau, Alaska 99811-0806
(907) 465-2547
E-mail: license@dced.state.ak.us
DOCUMENTATION OF DISABILITY-RELATED NEEDS
Dear Applicant:
If you have a learning disability, a psychological disability, physical disability, or other disability that requires an accommodation
in testing, please have this section completed by an appropriate professional (education professional, doctor, psychologist,
psychiatrist) to certify that your disabling condition requires the requested test accommodation.
IF YOU HAVE EXISTING DOCUMENTATION OF HAVING THE SAME OR SIMILAR ACCOMMODATION PROVIDED TO
YOU IN ANOTHER TEST SITUATION, PLEASE PROVIDE INFORMATION.
Please have appropriate professional complete the portion below.
I have known
since
in my capacity
(test applicant)
(date)
as a
. Diagnosis of applicant is
.
The applicant has discussed with me the nature of the test to be administered (if additional information is needed regarding
the examination, please contact the division at the above telephone number). It is my opinion that because of this applicant's
disability, he/she should be accommodated by providing the information (since all the accommodations listed below may not
be available, please note ALL that would apply):
Taped test
Large print test
Reader
Scribe/amanuensis
Extended time:
Time-and-a-half
Double time
More than double time (please justify)
Separate testing area
Use of computer or other adaptive equipment (please specify)
Other (please specify)
Signature:
Printed Name:
Address:
Telephone Number:
Date:
Type of License:
08-4193e (Rev. 2/01)
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