Request for special accommodations

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Request for special accommodations The complete Special accommodations RSA Form (filled by a candidate), together with the documents, giving official confirmation of a disability, are to be sent to the address: 340 S. Lemon Ave, # 7387Walnut CA 91789 or to the Email address: [email protected] Documents, confirming a candidate’s disability, must be signed by a physician or another doctor. Full name_____________________________________ ______________________________________________ Address______________________________________ ______________________________________________ Email address________________________________ ______________________________________________ Phone number _______________________________ Additional telephone number_________________ ______________________________________________ Insurance policy number______________________ ______________________________________________ Description of disability _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________

Request for special accommodations Date of assessment of disability____________________________________________ Required special conditions________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Signature___________________ Date_______________________

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