EXCEPTIONAL CIRCUMSTANCES EXEMPTION REQUEST FORM

Requests for exemption to the Policies and Procedures of The CELBAN Centre must be made via this form only. Requests by telephone, email, or fax will not be accepted. The CELBAN Centre defines an exceptional circumstance as any unforeseen circumstance beyond the examinee’s control, which could reasonably affect their ability to write CELBAN (e.g. family emergency, illness, extreme weather). Human error on the part of the examinee is not grounds for an exceptional circumstance exemption. Before completing this form, please review our Policies & Procedures.

To request an exemption to the Policies and Procedures of The CELBAN Centre, please complete and submit the form below.
Please attach all necessary supporting documentation (such as a doctor’s note – license number must be included, next of kin death notice, letter from an official, flight cancellation notice, etc.).

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 10 business days. To avoid delays, please submit the form only once and ensure all information is correct.

SPEAKING TEST DATE

yyyy-mm-dd

COMPUTER BASED TEST (CBT) DATE

yyyy-mm-dd

PLEASE SPECIFY THE TEST APPOINTMENT THE EXEMPTION 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 circumstance:

PLEASE DESCRIBE THE EVIDENCE THAT YOU ARE PROVIDING
FOR YOUR CLAIM

A clear and concise description of documentation or references provided:

SUPPORTING DOCUMENTATION

Documentation providing evidence of the exceptional circumstance (such as a doctor’s note – license number must be included; next of kin death notice; letter from an official; flight cancellation notice, etc.)
Supporting documentation from a healthcare or counselling professional which indicates a diagnosis of mental health or physical illness that prevents the examinee from completing the test (healthcare or counselling professional must provide license number in the documentation).

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

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