Testing Department
Special Administration Request
DISABLED
Instructions:
1.    Contact the Coordinator of Testing Services at ext. 74233 to schedule a testing
        date and time.
2.    Complete this form and attach it to any testing materials.
3.    Deliver all testing materials to Testing Services, Rm. 1303,  at least 24 hours prior to the
        scheduled testing date and time.
DO NOT SEND THE TEST WITH THE STUDENT
Date/Time the test is to be administered:    Date: _________________________
                                                                Time:_________________________
                                                                Time Allotted: __________________

Student's Name: (Print): _______________________ Student #: _____________

Student's Signature: _________________________________________________

Test should be completed by (date):  _____/____/____

Closed Book____    Open Book____    Calculator____    No Calculator____

Specific instructions or conditions not printed on this test:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Instructor's Name: (Print): ______________________ Signature:______________

Instructor's Office #: _____________    Ext. # _______________

(This section is to be completed by Testing)

Returned to:    (Print)_______________________________    Date:____________

                       (Signature) _____________________________________________

START TIME: _____________            STOP TIME: ____________

This test was administered on: _____/_____/_____   by:______________________

Instructor was called for pick-up of this test on: DATE: ________________________