TESTING ACCOMMODATION REQUEST FORM

This form must be filled out in its entirety.

RETURN TO AMERICAN BOARD OF COMPREHENSIVE CARE 630 WEST 168th STREET Box 6 NEW YORK, NY 10032

If you wish to use FedEx, please address to: AMERICAN BOARD OF COMPREHENSIVE CARE 617 WEST 168th STREET NEW YORK, NY 10032

TO BE COMPLETED BY THE APPLICANT

Applicant Name	____________________________________	Email______________________________________
Phone Daytime	____________________________________

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Please check the accommodations you are requesting for this exam. The final determination of accommodations for this exam will be made in accordance with disability documentation.
Extended Time (amount):_______	Computer	Voice Recognition Software	Other__________________
Smaller Proctored Environment	Calculator	Large print

I certify that all the information contained in this form is true and correct.

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Applicant                                                                                                 Date

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