Student name*:

                            Student ID*:

                   Student phone:

  Faculty Member name*:

                     Faculty Phone:                                                

                        Department*:

                     Email Address:

        Course Name, Number & Section*:

  Date & Time of Exam to be administered*:               

  Accommodations requested for the exam(s), (i.e.: extended time, reader, enlarged exams etc):  

  Name of person submitting the request*:
             (please indicate faculty or student)    student faculty

  I agree with these arrangements*. (Form will not be processed if this box is not checked).