The information provided by this form is intended solely for use in the event of a medical emergency or incident that
may occur during the bar examination. Only the Board, the Board’s staff, proctors, and emergency medical
personnel will have access to this information.
MASSACHUSETTS BOARD OF BAR EXAMINERS
Request for Special Arrangement
for a Health-Related Condition
Applicant Name (please print): ___________________________________________________
Date of Birth: _________________________
Tel. #: _____________________________
□ Boston □ Spr
ingfield Section/Room _______________ Seat # __________________
Approved by: __________ Date: __________ Applicant Notified: ________ Date: ______________
E-mail: ____________________________
Nature of Request: _____________________________________________________________
_____________________________________________________________________________
Medication(s): ________________________________________________________________
Equipment: ___________________________________________________________________
Other: _______________________________________________________________________
Contact Information in case of emergency:
Medical Professional’s Name/Tel. #: _______________________________________________
Emergency Contact Person’s Name/Tel. #: __________________________________________
Applicant’s Signature: __________________________________________________________
Send this form, at least 3 weeks prior to the first day of
the bar exam, to:
Board of Bar Examiners
John Adams Courthouse, Suite 5-140
One Pemberton Square, Boston, MA 02108
OR
Attach completed form and email to:
info@bbe.state.ma.us
For Board of Bar Examiners Use Only:
R
ev. 10/2019
click to sign
signature
click to edit
![]()
