ACCOMMODATION NOTIFICATION REQUEST
I, , am requesting accommodation notification be forwarded
to the following instructors for semester 20___.
1. Course Prefix & Number: Instructor:
Name of Course:
2. Course Prefix & Number: Instructor:
Name of Course:
3. Course Prefix & Number: Instructor:
Name of Course:
4. Course Prefix & Number: Instructor:
Name of Course:
5. Course Prefix & Number: Instructor:
Name of Course:
6. Course Prefix & Number: Instructor:
Name of Course:
7. Course Prefix & Number: Instructor:
Name of Course:
The above is a list of all instructors I request be notified of my accommodation. I
understand that if there are any changes, it is my responsibility to notify Disability
Services and instructors not listed above will not receive accommodation notification.
S
ignature: Date:
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