FORM B

REASONABLE TESTING ACCOMMODATIONS
All required forms and evaluations MUST be submitted
at the time your application for admission is filed. There are no exceptions to this requirement.

DISABILITY DOCUMENTATION

(To be completed by a physician or licensed professional for the applicant)

NOTE: The New Mexico Board of Bar Examiners requires current documentation (within the last three years) from a licensed physician or professional in the field related to the applicant's disability. The applicant must return this form with his/her completed Application for Admission to the New Mexico State Bar.

(Please type or print legibly)

Physician or licensed professional:

Name:________________________________________________________________

Title:_________________________________________________________________

License/Certification Number:_____________________________________________

Address: ______________________________________________________________

______________________________________________________________________

Phone number:__________________________________________________________

Re: Applicant’s Name:____________________________________________________

Please describe your credentials which qualify you to diagnose and/or verify the applicant’s disability and to recommend an accommodation: _________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

What is the specific diagnosis, condition, or physical impairment that requires testing accommodations? _______________________________________________________________________

_______________________________________________________________________

Briefly describe the nature of the condition and describe how this condition affects the applicant. _______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Current treatment consists of: ______________________________________________

_______________________________________________________________________

_______________________________________________________________________

Last date of treatment/consultation with applicant:______________________________

Length of time treating applicant:____________________________________________

Is this a permanent condition/disability? ____ YES ____ NO

If no, when is the condition/disability likely to abate? ___________________________

_______________________________________________________________________

In what way does the condition/disability affect the applicant’s ability to read, write and/or concentrate for extended periods of time? __________________________________________________________________

_______________________________________________________________________
_______________________________________________________________________

Based on the person’s condition/disability and your diagnosis, what testing accommodations would you recommend? (Check all that apply)

___ Braille version of test

___ Large print test book ___ 18 point ___ 24 point

___ Audio cassette version of test

___ Use of tape recorder

___ Use of reader

___ Use of transcriber

___ Other:______________________________________________________________

___ Additional testing time. Please specify the amount of additional time for each part of the exam.

Written exam (essay and multistate performance test questions):___________________

_______________________________________________________________________

Multistate exam (multiple choice questions):___________________________________

_______________________________________________________________________

Please explain how the recommended accommodation relates to the disability:_______________________________________________________________

Do you have written evaluations on the applicant’s disability/condition? ___ YES

__ NO If yes, please attach copies of the evaluation(s).

I certify that all the information on this form and that attached hereto is true and correct to the best of my knowledge and belief. I understand this information may be reviewed by a physician or licensed professional retained by the New Mexico Board of Bar Examiners to assist in determining reasonable testing accommodations.