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, position, name of the educational institution, company or other employer, address, and telephone number.

2.	Name the course of study in which the above-named applicant was enrolled at your educational institution or name the applicant's position of employment.

3.	Provide the dates during which the applicant was enrolled or employed.

4.	Was the applicant granted non-standard testing or working accommodations for a disability?

5.	State the nature of the physical or mental impairment that served as the basis for granting non-standard testing or working accommodations, and the evaluation process used by your organization to determine whether the person's request for non-standard accommodations should be granted?

6.	Specifically describe the accommodations granted to the applicant. (If non-standard testing accommodations were granted to the applicant, fully describe any changes in standard or customary testing procedures that were granted to the applicant.)

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 for Educational Institution or Employer

(Sign in black ink)