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

CERTIFICATE

1.	Provide your name, address and telephone number. Describe the professional qualifications (terminal degree, clinical specialty, licensure, etc.) that qualify you to act in the capacity of a medical or psychological authority concerning the applicant's physical or mental impairment. Attach a current copy of your curriculum vitae.

2.	List the date(s) on which you personally examined the applicant.

3.	List the clinical procedures you employed to make the diagnosis of a disability. Include the complete names of tests or special procedures you employed. Attach a copy of all pertinent medical or psychological records. Include results of laboratory studies and diagnostic tests, and raw and scale score data of psychological, psychoeducational, or neurological assessments.

4.	List the complete ICD-9-CM (International Classification of Diseases, Ninth or most current edition, Clinical Modification) diagnosis of the physical impairment or the complete multiaxial DSM-IV (Diagnostic and Statistical Manual of Mental Disorders) diagnosis of the mental impairment. Include all relevant severity and course specifiers.

5.	Describe the nature and severity of the applicant's physical or mental impairment and discuss its effects on the ability of the applicant to take the bar examination under standard testing conditions.

6.	Recommend non-standard testing accommodations and discuss the relationship of the accommodations to the specific physical or mental impairment. If your recommendation for non-standard testing accommodations includes an extension of the standard or customary examination time, describe your rationale for the amount of time recommended.

I have read the foregoing document and have answered all questions fully and frankly. I declare, under penalty of law, that the answers are complete and true to the best of my knowledge.

Signature of Medical, Psychological, or Educational Authority

(Sign in black ink)