This form is for college professors, teaching assistants, academic advisors, and other college officials who may answer the questions below that addresses these topics. 

All fields marked with asterisk (*) are required.

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(xxx-xxx-xxxx)
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(If you believe this student has endured special circumstances or has faced unusual challenges during his/her life, please describe them. Also, please give example(s) of how the student has found support and demonstrated resiliency to function well in academic and personal settings.)
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I certify that all information on this form is correct.*
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