Request for Special Exam Accommodations

I am applying for a Request for Special Exam Accommodation for the   --Select-- Winter Fall Spring Summer   Semester* and   --Select-- 2019 2020 2021 2022 2023 2024 2025   Term* .

Last Name:*  

First Name:*  

Student ID Number:*  

(Do not use ssn)

SHU Email:*  

Division:*  
----- LD1 LD2 LD3 LE1 LE2 LE3 LE4

Address:*  

City:*  
 

State:  
-- AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip:*  

EXAMINATIONS

** List all of your in-class examinations in date order.

Date**	Time	Course Number (Ex: PUBG7801MM)	Course Name (Ex: Administrative Law)	Professor

Reason for Special Accommodations

Other

Please list any specific technology or physical space modifications needed and/or include any other information you believe is necessary.