IN THE SUPREME COURT OF THE STATE OF HAWAII

BEFORE THE BOARD OF BAR EXAMINERS

In the Matter of the Application

of

(Full legal name)

for

Admission to the Bar of the State of Hawaii

REQUEST FOR NON-STANDARD TESTING ACCOMMODATIONS

I, [full name] , request non-standard testing due to disability. In support of my request, the following required information is provided.

1.	I became disabled (date):

2.	The law school(s) I attended ___ did ___did not provide non-standard testing accommodations. The name, address, and telephone number of each law school that provided accommodations is:

A Form 8 Certificate of Non-Standard Testing Accommodations from each law school that provided accommodations is attached.

3.	The college(s) or university(ies) I attended ___ did ___ did not provide non-standard testing accommodations. The name, address, and telephone number of each college or university that provided accommodations is:

A Form 8 Certificate of Non-Standard Testing Accommodations from each college or university I attended is attached.

4.	My employers ___ have ___ have not provided non-standard testing or working accommodations. The name, address, and telephone number of each employer who provided accommodations is:

A Form 8 Certificate of Non-Standard Testing or Working Accommodations from each employer is attached.

5.	Testing organizations	___ have ___ have not provided testing accommodations. The name, address, and telephone number of each testing organization that provided accommodations is:

A Form 9 Certificate of Non-Standard Testing Accommodations from each testing organization is attached.

6.	In addition to the law school(s) and college(s) or university(ies) listed above, other educational institutions ___ have ___ have not provided non-standard testing accommodations. The name, address, and telephone number of each such institution that provided accommodations is:

A Form 8 Certificate of Non-Standard Testing Accommodations from each institution is attached.

7.	The name, address, and telephone number of each medical, psychological, or educational authority that examined me to assess the nature and extent of my disability is:

A Form 7 Certificate of Medical, Psychological, or Educational Authority is attached for each listed examiner.

8.	The physical or mental impairment for which I seek non-standard testing accommodations is (describe):

9.	I ask that the Hawaii Board of Bar Examiners provide the following non-standard testing accommodations:

10.	The non-standard testing accommodations requested herein will be enable me to demonstrate the essential skills and aptitudes required for admission to the bar, which I would not otherwise be able to demonstrate, by (explain):

11.	I have been provided non-standard accommodations in educational settings or employment as follows (describe in detail the accommodations provided by the educational institutions and employers listed above):

12.	The non-standard testing accommodations I have received from testing organizations include (describe in detail the testing accommodations provided by testing organizations):

I have read the foregoing document and have answered all questions fully and frankly. The answers are complete and true to the best of my knowledge.

I understand that this application is of a continuing nature and must provide correct and complete information to and including the date of my appearance to take the attorney's oath. I will notify the Hawaii Board of Bar Examiners, in writing, of any change to information provided with this request, information hereafter developed, and any subsequent incident that could have any bearing upon the information provided herein.

I declare, under penalty of law, that the foregoing is true and correct.

Signature (black ink):