7. How does the accommodation you selected relate to the applicant’s disability given the format
of the examination? Relate any comments to each exam for which any accommodation is
recommended.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
I certify that all of the information I have provided is true and correct.
_____________________________________________ __________________________________
Evaluator Name
Title
_____________________________________________ __________________________________
Business Name
Phone (enter 10 digit #)
_____________________________________________ __________________________________
Signature
Date (mm/dd/yyyy)
Once this form has been completed, send it to the address listed above or you can also return it to
the applicant to submit with their accommodation request. The board will not review the applicant’s
request until both forms have been received.
DOH 668-080 April 2013
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