Full name:
 

Student ID:
 

Mount A e-mail:
 

Phone number:
 

Mount A mailbox (if applicable):
 

Mailing address:

 

 

I am applying for accommodation for the following exam(s):

1. Course title:
 
Course code:
 
Instructor name:
 
Exam date:
 
Exam time:
 


2. Course title:

 
Course code:
 
Instructor name:
 
Exam date:
 
Exam time:
 
 

 3. Course title:
 
Course code:
 
Instructor name:
 
Exam date:
 
Exam time:
 


4. Course title:
 

Course code:
 
Instructor name:
 
Exam date:
 
Exam time:
 
 
5. Course title:
 

Course code:
 
Instructor name:
 
Exam date:
 
Exam time:
 


6. Course title:
 

Course code:
 
Instructor name:
 
Exam date:
 
Exam time:
 

 

My request is based on the following circumstance:

                     

Additional details:
   

 

 

I am able to provide appropriate documentation to support my request if asked:

                     

I understand that misrepresentation of an illness or circumstances (as listed on our exam accommodation information page) constitutes academic dishonesty.


  Have you previously applied for exam accommodation at Mount Allison?

                    

If I am granted an exam accommodation, I am eligible for services provided by either The Meighen Centre or the student life office.

                    

By submitting this form, I acknowledge having read and understood the information detailed on this form.