Form 08-4161 - Residential Contractor Endorsement Application Page 3
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1
2
3CONFIDENTIAL
CONFIDENTIAL
STATE OF ALASKA
DEPARTMENT OF COMMUNITY AND ECONOMIC DEVELOPMENT
DIVISION OF OCCUPATIONAL LICENSING
RESIDENTIAL CONTRACTOR ENDORSEMENT
P.O. BOX 110806, JUNEAU, ALASKA 99811-0806
(907) 465-2546 or 465-3035
E-mail: license@dced.state.ak.us
DOCUMENTATION OF DISABILITY-RELATED NEEDS
Dear Applicant:
If you have a learning disability, a psychological disability, a physical disability, or other disability that requires a
testing accommodation, please have this section completed by an appropriate professional (education professional,
doctor, psychologist, psychiatrist) to certify that your disabling condition requires the required testing
accommodation.
IF EXISTING DOCUMENTATION OF THE SAME OR SIMILAR ACCOMMODATION WAS PROVIDED TO YOU
IN ANOTHER TEST SITUATION, PLEASE PROVIDE INFORMATION.
Please have appropriate professional complete the portion below and return to the Division of Occupational
Licensing.
I have known
since
in my capacity as
(Test Applicant)
(Date)
a
. Diagnosis of applicant is
(Professional Title)
.
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 following (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:
Date:
Type of License:
License Number:
08-4161a (Rev. 2/00)
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