Special Accommodations Verification Request Form

Special Accommodations

Verification Request Form

A Licensed or otherwise Qualified Professional whose credentials are appropriate to diagnose and

evaluate the candidate’s physical or learning disability and make recommendations for testing

accommodations must complete this form. The professional must have treated and/or diagnosed the

candidate within the last five (5) years and have knowledge of the candidate’s current level of function.

Attach additional sheets as needed. A copy of the documentation (e.g. educational assessment,

psychological report) dated within the last five (5) years that provides diagnostic/clinical data (e.g., scores

from educational testing) confirming the diagnosis, and the need for the testing accommodation as well

as accommodation recommendation(s) must be enclosed with this form for all learning disabilities. If the

last examination and/or report is over five (5) years old, please contact the FINRA Accommodations

Team for additional guidance.

I: Licensed/Qualified Professional Information

Licensed/Qualified Professional’s Name: ___________________________________________

Title: _______________________________________ License #: _______________________

License Granting Authority: ______________________________________________________

Institution/Practice Name: _______________________________________________________

Address: ____________________________________________________________________

City: ____________________________________

State: ______

Zip Code: __________

Country: _______________

Daytime Telephone: (

) ________________________

II: Candidate Disability Status: (Check all that apply)

Physical _____

Learning _____

Hearing Impaired _____

Vision Impaired _____

Other (Specify): ________________________________________

III: Diagnosis and Treatment Information

A. Specified Diagnosis:_________________________________________________________

Please note: If this is a specific learning disability, learning-related or psychological disability, please

provide identification of the DSM-III-R or DSM-IV diagnosis. (Enclose copy of psychological or

educational assessment report. An individual self-assessment is not acceptable.)

B. Describe the manner in which this disability impairs major life activity/functioning:

C. Last date of your most recent treatment or consultation with the candidate and date you first saw the

candidate for this condition:

Personal Confidential Information

Special Accommodations Verification Request Form - Finra