GENERAL INFORMATION |
Personal Information |
Please enter your personal information. |
1. | Full Name | John Smith |
Social Security Number | ***-**-**** |
Contact Information |
2. | Address |
Street or P.O. Box # | 3855 Lake Clearwater Place |
Apt. # or Address 2 | Apt. 222 |
City | California |
State | Florida |
Zip | 90210 |
Preferred Contact Number | (812)111-5100 |
Alternate Number | (574)111-4303 |
Country |
Examination |
3. | Please select examination. |
Law School |
4. | Provide the following information for law school. |
School Name |
Address 1 |
Address 2 |
City |
State or Province |
Zip Code |
Dean of Students' Email |
Attended From |
Attended To |
Degree Conferred or Expected to be Conferred |
Previous Examination |
5. | Please enter your previous bar examinations. |
Have you previously applied to take the Indiana Bar Examination? |
Please state the month and year of the last exam for which you filed an application. |
Have you previously requested accommodations on the Indiana Bar Examination? |
Please state the month and year of the last exam for which you requested accommodations. |
Were you awarded accommodations for that examination? |
DISABILITY DESCRIPTION AND HISTORY |
Your Disability Status |
6. | Check the disability or disabilities for which you are requesting accommodations. |
Learning Disability |
ADHD/ADD |
Physical Disability |
Visual impairment |
Hearing Disability |
Psychiatric Disability |
Other (describe): | ||
List your age when first diagnosed. |
Are you currently being treated? |
If yes, provide the name, qualifications, and telephone number of your treating professional(s). | ||
List any treatment and/or medication currently prescribed for the disability or disabilities identified above, or list “none.” | ||
Is the treatment or medication effective in controlling symptoms? |
If no, describe remaining symptoms and any side effects. | ||
If there is anything else you would like the Indiana Board of Law Examiners to know about your disability and need for accommodations, you may UPLOAD a personal narrative. |
TESTING ACCOMMODATIONS REQUESTED |
Testing Accommodations Requested |
List all accommodations you are requesting for the Indiana bar examination. | ||
Do you request extra time to take the bar exam? |
Essay sessions: Specify the amount of time requested for each session (i.e. one extra hour, double time): |
AM (MPT 1 & 2 3 hours) |
PM (Indiana Essays 1-6 4 hours) |
MBE sessions: Specify the amount of time requested each session (i.e. one extra hour, double time): |
AM (100 multiple choice questions – 3 hours): |
PM (100 multiple choice questions – 3 hours): |
Do you request extra breaks to take the bar exam? |
Describe the duration and frequency of the requested breaks? | ||
Other arrangements (e.g., elevated table, limited testing time per day, lamp, medication, etc.). Describe the arrangements. | ||
PAST ACCOMMODATION HISTORY |
History of Accommodations |
Did you receive testing accommodations in Law School? |
Explain | ||
Did you receive testing accommodations during your Undergraduate Studies? |
Explain | ||
Did you receive testing accommodations for Secondary Education (High School)? |
Explain | ||
Did you receive testing accommodations or other services during Elementary Education? |
Explain | ||
15. | Did you receive accommodations for any of the following standardized tests: |
LSAT |
GMAT |
SAT |
MICAT |
ACT |
MPRE |
GRE |
TOEFL |
NOTE: If you took an exam multiple times but did not receive accommodations for all administrations of the exam, please so indicate. |
Did you receive accommodations or disabled-student services in high school, including but not limited to accommodations or services provided as a result of an Individualized Education Plan (IEP) or a 504 Plan? |
Explain | ||
Did you receive accommodations or disabled-student services in elementary or middle school, including but not limited to accommodations or services provided as a result of an IEP or a 504 Plan? |
Explain | ||
SUPPORTING DOCUMENTATION |
Medical Documentation |
Medical Documentation
Personal Statement Provide a personal statement describing when you first became impaired by your disability, when you were first formally diagnosed, how your disability impacts your daily life activities, including your educational and testing functioning, and how your disability affects your ability to take the bar examination under standard testing conditions. Please explain how each accommodation requested alleviates the impact of your disability. If English is a second or foreign language, please include the age at which you first began speaking and learning English. Proof of Past Accommodations Provide proof of past accommodations received, if any, for law school, college, and prior standardized examinations (i.e., LSAT, SAT, MPRE, TOEFL, etc.). Test Scores and Transcripts For applications based on Learning Disabilities, ADHD, or other cognitive disorders, you must provide copies of your score reports on the SAT and LSAT, and transcripts from all colleges and law schools attended. If English is a foreign or second language, you must provide any TOEFL scores you have received. Prior or Concurrent Bar Examinations If you have ever applied for a bar examination in any jurisdiction other than Indiana, or if you are applying for a concurrent bar examination, list each such jurisdiction and complete the information below. |
Have you have ever applied for a bar examination in any jurisdiction other than Indiana, or if you are applying for a concurrent bar examination? |
Jurisdiction |
Mo/Yr Exam |
Accommodation Requested |
Granted/Denied |
Please describe | ||
Did you pass? |
CERTIFICATION |
Certification |
I am aware that it is my responsibility to file a timely and complete application for testing accommodations. I understand that my original signed and notarized application must be received in the Board’s office by the general application deadline. I also understand that all required supporting documentation must be submitted with my application. I understand that if my application is late or incomplete, it may be rejected and not considered by the Board. |
I certify under penalties for perjury that all of the information and statements made by me herein are true and correct to the best of my knowledge and belief and that I am under a continuing obligation to provide truthful and correct information to the Board |
AUTHORIZATION AND RELEASE |
Authorization and Release |
I am in connection with my application for testing accommodations on the bar examination, authorize the Indiana State Board of Law Examiners (Board) to provide, at its discretion, a copy of any and all documentation that I submit in connection with this application, including any confidential medical records or information, to such personas and/or consultants as the Board may deem necessary to evaluate my application for testing accommodations adequately. If requested by the Board, I further agree to submit to diagnostic testing by a physician, psychologist or other qualified professional chosen by the Board. If further information regarding the documentation that I have provided is needed, I authorize the Board to contact the professional(s) who diagnosed and/or treated my disability. I further authorize such professionals to communicate with the Board in this regard to provide such clarification and/or further information and documentation as the Board requires. I authorize the Board to contact those entities which have provided me testing accommodations or with whom I have a current application for testing accommodations pending to ascertain what accommodations have been or will be granted or denied. I further authorize such entities to communicate with the Board in this regard to provide such clarification and/or further information and documentation as the Board requires. I hereby release, discharge, and exonerate the Indiana State Board of Law Examiners, its agents, and representatives and/or any person from any and all liabilities of every nature and kind arising out of the furnishing. Inspection or receipt of medical records, documents, records and other information, or any investigation made by or on the Board's behalf. |
I certify under penalties for perjury that all of the information and statements made by me herein are true and correct to the best of my knowledge and belief and that I am under a continuing obligation to provide truthful and correct information to the Board |
After you submit your application, you MUST upload supporting documentation. |