REQUEST FOR SPECIAL TESTING
If you claim to have a physical or mental impairment that substantially limits a major life activity, you may be eligible for accommodations
in the testing process which will ensure that the test accurately reflects your skills, knowledge, and abilities. Attempts will be made to
provide a reasonable accommodation which will allow you to demonstrate your abilities.
The information requested below, and any documentation regarding your disability or need for accommodation in testing, will be
considered strictly confidential and will not be furnished to any outside source without your permission.
Name (Last, First, MI):
Mailing Address (Street, City, State, Zip):
Phone Number:
Accommodation requested for which examination?
ACCOMMODATION REQUESTED
The following accommodations are requested to provide me (the examinee) with an accessible testing arrangement. Please be specific,
for example, "Test should be printed in black ink," or "I will need a magnifying glass to read the test."
1.
5.
4.
3.
2.
(If extra space is needed, please attach another sheet.)
Requestor Signature Date
Staff Signature Date
Panola College is an Equal Opportunity Institution that provides educational and employment opportunities on the basis of merit and without discrimination because of race, color,
religion, sex, age, national origin, veteran status, disability or genetic information.
Updated 4/1/2014
