*Fort Garry student
*Bannatyne student
*William Norrie Centre / Inner City Social Work

*First Name:

*Last Name:

*Student Number:

*Email OR Telephone#

*Course: Faculty Code & Number (e.g. PSYC 1200)
Code: Number:

*Section Number

*Instructor's Name

*Instructor's Contact Information

Please list the instrutor's EMAIL or TELEPHONE number in the space provided. If you have both the instructor's telephone number and email please include both in the space provided

Contact Info:

*Date of Test: (MM/DD/YYYY)

*Time of Test:

Start Time:

Finish Time:

*Location of Test
(ROOM & BUILDING where the class is writing the test):

Do you require an early start? YES NO

If "YES", what time?

Do you require an Adaptive Tech; Dragon, Zoomtext, Kurzweil? (only if part of your accommodation)
Please Specify

Do you require a Computer? (only if part of your accommodation) YES NO

Do you require a reader/scribe? (only if part of your accommodation) YES NO

Course #2: Faculty Code & Number (e.g. PSYC 1200)
Code #2: Number #2:

Section Number #2

Instructor's Name #2

Instructor's Contact Information #2

Please list the instrutor's EMAIL or TELEPHONE number in the space provided. If you have both the instructor's telephone number and email please include both in the space provided

Contact Info #2:

Date of Test #2: (MM/DD/YYYY)

Time of Test #2:

Start Time #2:

Finish Time #2:

Location of Test #2
(ROOM & BUILDING where the class is writing the test):

Do you require an early start#2? YES NO

If "YES", what time#2?

Do you require an Adaptive Tech; Dragon, Zoomtext, Kurzweil? (only if part of your accommodation)
Please Specify

Do you require a Computer? (only if part of your accommodation) YES NO

Do you require a reader/scribe? (only if part of your accommodation) YES NO

Course #3: Faculty Code & Number (e.g. PSYC 1200)
Code #3: Number #3:

Section Number # 3

Instructor's Name #3

Instructor's Contact Information #3

Please list the instrutor's EMAIL or TELEPHONE number in the space provided. If you have both the instructor's telephone number and email please include both in the space provided

Contact Info#3:

Date of Test#3: (MM/DD/YYYY)

Time of Test#3:

Start Time#3:

Finish Time#3:

Location of Test #3
(ROOM & BUILDING where the class is writing the test):

Do you require an early start#3? YES NO

If "YES", what time#3?

Do you require an Adaptive Tech; Dragon, Zoomtext, Kurzweil? (only if part of your accommodation)
Please Specify

Do you require a Computer? (only if part of your accommodation) YES NO

Do you require a reader/scribe? (only if part of your accommodation) YES NO