4/8/2014 Form A-Page 1FORM A: APPLICANT REQUEST FOR TEST ACCOMMODATIONS NOTICE TO APPLICANT: This form is part of your request for test accommodations on the bar examination. This form and all other applicable forms and required documentation must be filed at the same time as your application for admission. If additional space is needed to respond to any item, please attach a separate page. Do not leave any blanks or answer 223see attached.224 Full name: Date of birth: I.YOUR DISABILITY STATUS1.Check the disability or disabilities for which you are requesting accommodations, onlydisabilities noted here will be considered. Learning disability Visual impairment ADHD Hearing impairment Physical disability Psychological disability Other (describe) I was professionally diagnosed with (state specificdiagnosis) in (month), (year). This disability is temporary / permanent.The diagnosis was made by: Health care provider: Type of health care provider: Current address: Current City/State/Zip: Current phone number: Fax: List your age when first diagnosed. Are you currently being treated? Yes yes, provide the name, qualifications, and telephone number of each treating professional. American LegalNet, Inc. www.FormsWorkFlow.com 4/8/2014 Form A-Page 26.List any treatment and/or medication currently prescribed for the disability or disabilitiesidentified above, or list 223none.2247.Is the treatment or medication effective in controlling symptoms? Yes No N/A If no, describe remaining symptoms and any side effects.II.HISTORY OF ACCOMMODATIONSFor questions 1 through 5 below, please follow these instructions: If you were granted accommodations, check 223Yes.224 List the condition or diagnosis for which accommodations were granted, the specific accommodations granted, the educational institution or testing agency that granted the accommodations, and the time frame. If you did not request accommodations, check 223Not requested.224 Explain why you did not request accommodations. If you were denied accommodations, in whole or in part, check 223Denied.224 List the month and year the request was made, the condition or diagnosis for which accommodations were requested, the accommodations requested, the educational institution or testing agency, and the reason given by the entity for the denial. Note: if your request for accommodations was granted in part and denied in part, you should check both 223Yes224 and 223Denied.224 If you did not attend the type of school or take that exam, check 223N/A.224 1.Did you receive accommodations for the bar examination taken in another jurisdiction? Yes Not requested Denied N/A American LegalNet, Inc. www.FormsWorkFlow.com 4/8/2014 Form A-Page 32.Did you receive accommodations for the Multistate Professional Responsibility Examination (MPRE)? Yes Not requested Denied Not applied yet Awaiting NCBE Decision 3.Did you receive accommodations in law school? Yes Not requested Denied 4.Did you receive accommodations in college (undergraduate or graduate studies)? Yes Not requested Denied 5.Did you receive accommodations for any of the following standardized tests? LSAT Yes Not requested Denied N/A MCAT Yes Not requested Denied N/A GRE Yes Not requested Denied N/A GMAT Yes Not requested Denied N/A SAT Yes Not requested Denied N/A ACT Yes Not requested Denied N/A American LegalNet, Inc. www.FormsWorkFlow.com 4/8/2014 Form A-Page 46.Did you receive accommodations or disabled-student services in high school, including but not limited to accommodations or services provided as a result of an Individualized Education Plan(IEP) or a 504 Plan? Yes Not requested Denied N/A 7.Did you receive accommodations or disabled-student services in elementary or middle school, including but not limited to accommodations or services provided as a result of an IEP or a 504Plan? Yes Not requested Denied N/A III.ACCOMMODATIONS REQUESTED FOR THE TEXAS BAREXAMINATION (CHECK ALL THAT APPLY)For each accommodation you are requesting, explain why the accommodation is necessary and how it alleviates the impact of your disability or disabilities in the context of taking the bar examination Test question formats: Specific Rationale: Braille Audio CD Large print/18-point font Large print/24-point font Assistance:SpecificRationale: Reader Court Reporter/Scribe MBE Grid Assistance American LegalNet, Inc. www.FormsWorkFlow.com 4/8/2014 Form A-Page 5 Extra testing time. Indicate below how much extra testing time is requested: Day 1, Segment 1: Multistate Performance Test (MPT) 90-minute writing project (lawyering skills)Recommend: 275 for reading/organizing, 275 for writing Additional time requested 10% 25% 33% 50% Other (specify) Specific rationale for additional testing time on this segment Day 1, Segment 2: Procedure & Evidence Questions (P&E) 90-minute short answer exam Additional time requested 10% 25% 33% 50% Other (specify) Specific rationale for additional testing time on this segment Day 2: Multistate Bar Examination (MBE) 200-question standardized test divided into two 3-hour sessions Additional time requested 10% 25% 33% 50% Other (specify) Specific rationale for additional testing time on this segment Day 3: Texas Essays 12 essay questions in 6 subject areas, divided into two 3-hour sessions Additional time requested 10% 25% 33% 50% Other (specify) Specific rationale for additional testing time on this segment American LegalNet, Inc. www.FormsWorkFlow.com 4/8/2014 Form A-Page 6 Other arrangements (e.g., wheelchair access, elevated table, beverage, food, medication, lamp, magnifying glass, etc.). Describe the arrangements and provide a rationale for the request. IV.SUPPORTING DOCUMENTATIONRequests for test accommodations must be supported by the following documentation from third parties, which you must provide with your completed Form A: Applicant Request for Test Accommodations. Review the General Instructions for Requesting Test Accommodations for a detailed explanation of the supporting documentation you should submit. Medical Documentation Submit supporting medical documentation from a qualified professional who conducted an individualized assessment and who gave the diagnosis which forms the basis for the request for test accommodations. If you are requesting accommodations based upon more than one disability, you should supply medical documentation to support each disability. Verification of Accommodations History Provide verifying documentation of your accommodations history, if any. Submit a Form G, Certification of Accommodations History, completed by each educational institution or testing agency (hereinafter 223entity224) from which you requested accommodations in the past, whether granted or denied. Alternatively, you may provide other proof of your accommodations history, such as a copy of the letter(s) you received from the entity notifying you of the specific accommodations granted or denied. The proof should identify the time frame (e.g., third year of law school) and the nature of the disability (e.g., ADHD) for which any accommodations were granted or denied. If you received accommodations as a result of an Individualized Education Plan (IEP) or a 504 Plan, please provide copies of all IEPs or 504 Plans. Academic Transcripts Attach a copy of your LSAC Candidate Item Response Report. Attach copies of your undergraduate and law school transcripts only if you have a learning disability, ADHD or a cognitive disorder. Transcripts or report cards from elementary, middle, junior high, and high school, while not required, are helpful and may be requested in some cases. American LegalNet, Inc. www.FormsWorkFlow.com 4/8/2014 Form A-Page 7V.APPLICANT CHECKLISTReview this checklist carefully and checkmark the appropriate lines to indicate the documents you are submitting to request accommodations for the Texas Bar Examination. Submit this completed checklist with your request. I have carefully reviewed the General Instructions for Requesting Test Accommodations, particularly the section 223Steps for Submitting a Complete Request.224 1.The applicable disability verification form with comprehensive evaluation report and/orrelevant records attached Form B: Ph