EMP Request for Accommodations Form

  • EMA will provide reasonable and appropriate accommodations in accordance with the Americans with Disabilities Act (ADA) for individuals with documented disabilities who request and demonstrate the need for accommodation. Please submit this form so it is received by the EMA Certification Department at least 30 days in advance of the test date, and provide the required documentation if requesting an accommodation.

    Once the request for an accommodation is received and reviewed, the applicant may be contacted to obtain additional information. EMA will determine the feasibility of any accommodation, including the specific accommodation requested by the applicant/participant, taking into account all relevant circumstances including, but not limited to: the nature of the documented disability; the nature of the accommodation; and the accommodation’s impact on the certification examination.

  • Applicant Information

  • Home Phone Number (with area code)
  • Mobile Phone Number (with area code)
  • Personal email address
  • Special Testing Accommodations

  • Clear Signature
  • MM slash DD slash YYYY
  • Professional Evaluation

  • Professional evaluation must have been made no earlier than three (3) years prior to application
  • MM slash DD slash YYYY
  • I have been informed of the nature of the examination to be administered. It is my opinion that because of this candidate’s disability as described below he/she should receive the special testing accommodations requested above.
  • Max. file size: 10 MB.
  • Documentation of the requested accommodation must include documentation of need provided by an appropriate, licensed medical doctor, healthcare practitioner or other relevant professional on the professional’s letterhead. The documentation must include the candidate’s name and address as well as the diagnosis of the disability, history of previous accommodations, and specific request(s) for accommodations.

  • Work email address
  • Clear Signature
  • MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.