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Or testing agency (hereinafter "entity") from which you have requested accommodations, whether granted or denied. Please read, complete, and sign below before submitting this form to the entity for completion of the remainder of the 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 additio.

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