Office for Disability Services
Fidel Center Room, 154
Revised 6-20 TEK
Student Name: ______________________________ Banner ID: _________________________
E-mail: _____________________________________Phone: ____________________________
Semester: (Mark One) FALL SPRING SUMMER Year: ________________
I am requesting Letters of Accommodation for the following:
(Check ONLY if this pertains to you)
(example MATH )
Course No. / Section
(example. 101-01)
Instructor/Prof/TA Note-taking Alt. Text Other
My Academic Advisor is: _________________________________________
I, the undersigned, authorize the staff providing disability accommodation services to contact relevant
New Mexico Tech student services staff, faculty or administration to share information pertaining to my
accommodation(s) for the purpose of coordinating appropriate services and determining any necessary
and reasonable academic accommodations.
___________________________________________ __________
Student Signature Date
The institution will provide accommodations to students with disabilities to enable students to meet institutional
standards without compromising the Academic Integrity of the course, program, assignment or activity.
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