New York State
Department of State
Division of Licensing Services
Exam Unit (Special Testing)
P.O. Box 22001
Albany, NY 12201-2001
www.dos.ny.gov
Special Testing Arrangements Request
If you are an applicant who is seeking special testing arrangements due to a learning, physical, mental or psychological
disability, you should complete this form. Once complete, submit this form along with your supporting documentation
to the address above or to dosexams@dos.ny.gov.
PART 1: PERSONAL INFORMATION
Include your complete name, mailing address and daytime phone number. Note: It is important that we have a
phone number so that we may contact you for additional information and/or to make examination arrangements.
PART 2: TYPE OF EXAMINATION
Indicate the type of examination for which you are requesting special testing arrangements. Note: If your license type
requires both a written and practical examination, you are not required to request special testing arrangements for both.
PART 3: CLASSIFICATION OF REQUEST
Indicate the nature of the disability for which you are asking for special testing arrangements. If other,
please specify.
PART 4: ARRANGEMENTS REQUESTED
All exams with special testing arrangements will be administered to a reduced group size in a separate, low-distraction
area. Written examinations will receive 1 hour of extended time. Practical examinations will receive 30 minutes of
extended time. If you require additional accommodations, such as having a reader or scribe, list them here. Note: The
arrangements/accommodations must be appropriate to the disability.
PART 5: SUPPORTING DOCUMENTATION
You must submit supporting documentation from a physician or other qualified professional, or evidence of prior
accommodations from a school or other institution.
PART 1: PERSONAL INFORMATION
(Print or type)
LAST NAME FIRST NAME MIDDLE INITIAL
MAILING ADDRESS (NUMBER AND STREET) EMAIL ADDRESS
CITY STATE ZIP + 4 DAYTIME TELEPHONE NUMBER
( )
PART 2: TYPE OF EXAMINATION
(“X” all that apply)
Written Examinations
Notary Public Home Inspection Cosmetology
Real Estate Broker Hearing Aid Dispenser Esthetics
Real Estate Sales Private Investigator Nail Specialty
Security or Fire Alarm Installer Watch, Guard or Patrol Natural Hair Styling
Waxing
Practical Examinations
Hearing Aid Dispenser Cosmetology Nail Specialty
Barber Esthetics Natural Hair Styling
PART 3: CLASSIFICATION OF REQUEST
(“X” all that apply)
Learning Disability Physical Disability Other:
Hearing Disability Mental Disability
Wheelchair Access Psychological Disability
DOS-1591-f (09/19) Page 1 of 2
