TEST ACCOMMODATION REQUEST FORM

If you have a documented disability or special need, you may be able to receive test accommodations. Requests by telephone, email, or fax will not be accepted. The CELBAN Centre grants test accommodations depending on the nature of your disability or need, the supporting documentation provided, and the requirements of the test. The appropriate form of documentation must accompany any test accommodation request submission. Your test date and time may change, depending on the required accommodations. Before completing this form, please review The CELBAN Centre’s Policies & Procedures.

To request an accommodation for your test appointment(s), please complete and submit the form below.
Please attach all necessary supporting documentation which indicates the necessity and rationale for the accommodation
Please provide a detailed explanation on how the accommodation is the appropriate solution for the specific need of the examinee.
After submitting the form, you will receive an email confirming the request.
We will contact you again after we have assessed your submission. Please allow up to 20 business days. To avoid delays, please submit the form only once and ensure all your information is correct.

SPEAKING TEST DATE

yyyy-mm-dd

COMPUTER BASED TEST (CBT) DATE

yyyy-mm-dd

PLEASE SPECIFY THE TEST APPOINTMENT THE ACCOMMODATION REQUEST SHOULD BE APPLIED TO:

SPEAKING TEST
COMPUTER BASED TEST (CBT)
BOTH THE SPEAKING TEST AND CBT

EXAMINEE INFORMATION

CELBAN ID (if available):

Given (First) Name:

Family (Last) Name:

Date of Birth:

yyyy-mm-dd

Email:

Confirm Email:

EXAMINEE ADDRESS AND PHONE NUMBER

Street Number and Name:

City:

Province/Territory/State:

Country:

Postal Code/Zip Code:

Phone Number:

PLEASE DESCRIBE THE REASON FOR YOUR REQUEST

Statement of the nature of the disability and its severity:

PLEASE DESCRIBE THE TYPE OF ACCOMMODATION REQUIRED

A clear and concise description of the test accommodation(s) requested:

SUPPORTING DOCUMENTATION

Please upload at least one supporting document from a healthcare or counselling professional which indicates a diagnosis and describes your current limitation.

MS Word document, PDF, and graphic files are acceptable.

I testify that the information included on this form is accurate and truthful.