*Note that this list is not exhaustive nor are these accommodations guaranteed
**This form must be completed and turned in for each term you would like services**
SERVICE REQUEST FORM
Please make sure this form is completely filled out before turning in
Last Name ______________________________ First Name __________________________ C.W.I.D. Number______________________
Cell Number: ___________________________ E-mail ______________________________ Date _____________________________
ACCOMMODATIONS*:
I = Interpreter N = Notetaker EXT = Extended time on exams D = Distraction reduced room for exams
O = No Service ALT-T = alternative text needed Other: Please specify below (in Comments section)
STUDENT: You must account for each class you are enrolled in even if you do not want a “service.”
Accommodation
Example: (N)
Class Name
(BIOL)
Course #
(270)
Section
(1)
Course Title
(Principals of Human Physiology)
Campus Location
(Seaver-Malibu)
Instructor
(Jasperse, J)
Units
(4)
Total Units
COMMENTS:_____________________________________________________________________________________________________
Pepperdine University
Disability Services Office
Tyler Campus Center (TCC) 264
Phone: (310) 506-6500 Fax: (310) 506-6776
Term_________________
(Example: Fall 2010 = 2106)
