Alternative Testing Arrangements Request Form

A red asterisk * indicates a required field.

Alternative testing arrangements may only be applied to unscheduled test registrations.

Prior to submitting this form: • Register for the test(s) for which you are requesting accommodations. • Do not schedule your appointment. If you did schedule a test date, please cancel your appointment before completing and submitting this form.

Candidate ID Number:* (Found in your registration account)

First Name:*

Middle Initial:

Last Name:*

Last 5 digits of Social Security Number:*

Email:*

Confirm Email:*

Mailing Address:*

Address Line Two:

City:*

State/Province/Region:*

Zip/Postal Code:*

Country:*

Daytime Phone:*

Evening Phone:

Test(s) for which you registered: * Current Characters (Max 500): 0

For Individuals for Whom English Is Not a Primary Language Check here if English is not your primary language and you are indicating a request for an extension of testing time. By doing so you certify that the basis of your request is the fact that English is not your primary language. Note: this extension is not offered for tests in languages other than English. You must enclose documentation supporting your request that certifies that English is not your primary language. You may skip the next two questions if this is your only request.

Identify the disability for which you are requesting alternative testing arrangements:* Current Characters (Max 500): 0

List the specific alternative testing arrangement(s) that you are requesting (please note: only the requests listed will be considered):* Current Characters (Max 1000): 0

If you plan to bring a medical device into the testing room, please provide the make and model of any device(s) you intend to bring: Current Characters (Max 500): 0

Documentation (check one of the following)*:

I am requesting one of the alternative testing arrangements listed below because of a disability. Medical documentation is not required for the following accommodations: • Allowance of a medical device in the testing room. • Use of a trackball mouse. • Adjustable table. I am requesting alternative testing arrangements other than those listed above. Therefore, I have enclosed documentation, if required, as indicated on the current program website. I am requesting alternative testing arrangements other than those listed above. My institution has a copy of my documentation on file, and I am only requesting accommodations listed in section 8 of the Institutional Verification of Documentation Form. Therefore, I have submitted an Institutional Verification of Documentation Form, completed by an appropriate institution representative. I have been approved for alternative testing arrangements for this testing program in the past. The accommodations I am requesting and the condition of my disability have not changed. Therefore, the documentation I have previously submitted may be used.

Previous Alternative Testing Arrangements (check one of the following)*:

I have not previously been granted alternative testing arrangements. For a previous test session, I was granted the same alternative testing arrangements as I am currently requesting. For a previous test session, I was granted different alternative testing arrangements from those that I am currently requesting.

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I have read the current program website and hereby agree to abide by the conditions set forth, including the Rules of Test Participation, and I certify that I am the person whose name and address appear on this form. I have completed my registration for CASA IBT and submitted correct payment. I am submitting, together with this Alternative Testing Arrangements Request Form, any required documentation as noted on the program website. If my institution is submitting an Institutional Verification of Documentation on my behalf, I authorize that institution to submit a copy of the documentation referenced on that form to Evaluation Systems upon request. I understand that I should submit my request and all necessary documentation as early as possible in advance of my desired test date. I understand and agree that the alternative testing arrangements I have requested herein will be given due consideration. If, and to the extent that, any such request is granted, I understand that I will be taking the test under alternative conditions. Agree*

Please check the box below.

Please note, this form must be submitted with each registration.