Special Accommodations Eligibility Questionnaire Form

Special Accommodations

Eligibility Questionnaire

Member firms on behalf of their candidates with disabilities who are requesting accommodations for a FINRA

examination must complete this form and return it with the Special Accommodations Verification Form.

I. Candidate Information

Name: ______________________________________________________________________________

Address: ____________________________________________________________________________

City: ______________________________ State: __________

Zip Code: ___________________

Telephone Number (

) ___________________ E -mail Address: ____________________________

Candidate CRD/ FINRA ID# _____________________

Last 4 of SSN: XXX-XX- ___ ___ ___ ___

Exam Series #: _________________

Has the candidate received Accommodations from FINRA/NASD within the past 5 years? Yes/No

Specific accommodation(s) requested:

Paper & Pencil (Non-computerized) Exam ^ _________

Extra Time** __________Minutes

Reader/Recorder^ _________

Other: Please specify_________________________________________________________________

^ Upon contacting the testing vendor, please be advised that they require 10 business days to prepare for

appointments scheduled with these accommodations.

For Paper & Pencil Exams, please allow 5 business days after testing for your paper exam to be scored

and posted to Web CRD.

** If extra time is selected, the specific amount of extra time requested is required. Please see the attachment

for the standard examination lengths.

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II. Firm Information – please cross out and write “keep confidential” if you do not want your firm to

know about your disability and/or accommodations.

Firm Name_____________________________________________________ BD#________________

Registration/Compliance Officer Name: ___________________________________________________

Contact Email Address: _____________________________ Telephone #: (

) ___________________

Contact Signature: ________________________________________________ Date _______________

Note: All requests take approximately 2-3 business days to process after which a confirmation email will be

sent with the offered accommodations. All forms and supporting documentation may be faxed to FINRA at

(202) 303-3901 or emailed to .

If mailed, forms and documentation should be sent to the following address:

FINRA - Attention: Candidate Services

9509 Key West Avenue, 3rd Floor

Rockville, MD 20850

Personal Confidential Information

Special Accommodations Eligibility Questionnaire Form - Finra