Form 133.3 Texas State Securities Board P.O. Box 13167 Austin, Texas 78711-3167 (512) 305-8300 ADA Accommodations Request Form The Texas State Securities Board ("TSSB") complies with the Americans with Disabilities Act of 1990, as amended. To ensure equal opportunity for all qualified applicants with disabilities, TSSB will not pay any costs an applicant may incur in obtaining the required evaluation, diagnosis, and recommendations. Note: This form must be submitted each time the applicant requests to take an examination. 1. Biographical Information: Name: Date of Birth: Mailing Address (Street or P.O. Box): City: Telephone: 2. Examination Information: Requested examination date or window: Have you previously taken this examination? If yes, please provide: Date of last examination: Location of last examination: Were you provided special accommodations? If yes, what type of accommodations were provided? Fax: State: Email: Zip Code: CRD Number: G Yes G No G Yes G No 12-21-2011 American LegalNet, Inc. www.FormsWorkFlow.com Form 133.3 What is your requested accommodation? (Attach separate sheet if more space is needed.) 3. Information regarding disability. Supporting documentation, that is no more than three years old, must be submitted with this form. Please see guidelines on the following page. What is the disability that limits one or more of your major life activities (e.g., walking, hearing, speaking, seeing, reading or writing?) Please describe the special accommodations needed and include written documentation supporting the accommodation that you are requesting. (Attach separate sheet if more space is needed.) Supporting documentation must comply with the following: a. Be on official letterhead from a licensed or certified health professional appropriate for diagnosing and treating the disability; b. Make a recommendation for the specific accommodations with current, detailed documentation supporting the request; c. Provide evidence that similar accommodations have been made for you in other educational or testing situations or in employment settings, or describe why no such accommodation was made in the past but is now required; d. Be dated within the last three years; AND e. Be received by the application deadline. 12-21-2011 American LegalNet, Inc. www.FormsWorkFlow.com Form 133.3 Disability Documentation Guidelines These guidelines are developed to ensure candidates are protected under Title II of the Americans with Disabilities Act of 1990, as amended. The Securities Commissioner will evaluate all requests for examination modifications to determine whether the applicant: 1) has a disability, as defined by the ADA, and 2) is qualified for protection under Title II. Such modifications must maintain the security of the examination. Exam modifications that fundamentally alter the nature or security of the exam are not permitted. The following guidelines describe the necessary components of acceptable evidence required to validate a disability and the current need for testing accommodations. A prior history of accommodations, without demonstration of a current need, will not necessarily warrant approval of testing modifications. To avoid unnecessary delays, ensure the submission of all information and documentation by the application deadline and in accordance with these guidelines. Qualified individuals with disabilities are required to request accommodations every time they apply to take an examination by the application deadline for the respective examination. This requirement allows the Securities Commissioner to determine if the individual is "disabled" under the ADA. It also provides enough time to arrange reasonable and appropriate accommodations and services before the administration of the examination. Consequently, it is in the applicant's best interests to provide recent and appropriate documentation that clearly defines the extent and impact of the impairment(s) upon current levels of academic and physical functioning. � Requests for accommodations and appropriate, supporting documentation, which is complete, must be submitted by the application deadline. Documentation should provide evidence of a substantial current limitation to physical or academic functioning. Clinical evaluations should be performed by a licensed or qualified professional (e.g. physician, psychologist, or educator) who has conducted an examination of the candidate and has diagnosed a physical or mental impairment. Details about the professional's area of specialization and professional credentials, including certification and licensure, should be provided. Documentation must be submitted on official letterhead from a licensed or qualified professional who has examined the candidate and diagnosed a physical or mental impairment. Depending on the disability and written evaluation, documentation may include a letter from a physician or a detailed report. Documentation should not be more than three years old. Documentation for all disabilities should describe the extent of the disability, the criteria for the diagnosis, the diagnosis, the type and length of treatment and the recommended accommodation. Terms such as "problems," "deficiencies," "weaknesses," "differences," 12-21-2011 American LegalNet, Inc. www.FormsWorkFlow.com � � � � � Form 133.3 and "learning disabilities" are not the equivalent of a diagnosed specific disability (such as ADD, Dyslexia, Multiple Sclerosis, etc). The disability must be specific. The accommodation must also be specific. "Extended time" or "unlimited time" is not sufficient. The recommendation must be specific, such as an extra thirty minutes per session, time and one-half over one day, etc. � Indicate why specific accommodations are needed and how the effects of the specific disability are mediated by the recommended accommodations. Indicate any medication currently being taken that is directly linked to the disability and any effect that medication may have relating to the major life activity affected by the disability. All accommodations must be approved by the Securities Commissioner. Once accommodations have been granted, they may not be altered during the examination unless prior approval of the Securities Commissioner is obtained. Information Relating To Tests The following information should be shared with the health professional. This information will help them in formulating their response as it relates to each individual test. The TEXAS SECURITIES