Accommodations - Request Form

NMU IN:

First Name:
Last Name:

E-mail Address:

Street Address:

City:

State or Province:

ZIP:

Phone Number:
- -

Cell Phone Number:
- -

Semester Requesting:

Courses needing accommodations:

Add a course (up to 5)

Signature

By entering my initials in the box above: I understand that by submitting this form, I am giving the Coordinator of Disability Services permission to contact any or all of my evaluators and/or physicians for additional documentation and/or clarification.

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