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Is recommending accommodations on the bar examination for you on the basis of a psychological disability. Please read, complete, and sign below before submitting this form to the qualified professional for completion of the remainder of this form. Applicant s full name: Date(s) of evaluation/treatment: Applicant s date of birth: SSN: I give permission to the qualified professional completing this form to release the information requested on the form, and I request the release of any.

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