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Request for Test Taking

It is the student's responsibility to take this form to the instructor two weeks before the test to discuss testing arrangements. Allow enough advance time for the accommodations to be arranged.



________________________________ ________________________________
Student’s Name Today's Date
________________________________ ________________________________
Instructor Course
________________________________ ________________________________
Requested Testing Date Time (Include extended time if applicable)

DELIVER EXAM

_____ Instructor will leave test with the Campus Service Center (First Floor Peralta MOB)

_____ Student will pick up test from instructor.

_____ Instructor will email test to dhansen@samuelmerritt.edu



RETURN / PICKUP

_____ Student will submit test to the Campus Service Center (3100 Telegraph Avenue) for the instructor to pick up.  

_____ Student will return the test in a sealed envelope to instructor.  

ANY SPECIAL INSTRUCTIONS:

 

________________________________ ________________________________
Instructor Signature | phone Student Signature | phone

STUDENT ACCOMMODATIONS
Must be submitted to Assistant to the Dean one (1) week in advance.

_____ Computer (Specify program: ________________________________ )
_____ Extended time (Specify: ________ )  
_____ Test taped  
_____ Screen Reader