Date received
by AC _______________________
University of Minnesota Duluth
Before your test will be rescheduled, you MUST do the following:
1. Complete this form AND
2. Return the completed and signed form to Disability Services & Resources , 236 Kirby Student Center
***This form must
be in Disability Services & Resources within 24 hours of the test change***
Student Name: ____________________________ Dept & Course # _________________ Check one: ______My
“To be Announced” test will be: Date: ____________ Time: ________ ______My test date/time has
been changed: OLD test DATE: ___/___/___
TIME: _____ AM/PM until _____ AM/PM This change was made by (choose one):
Instructor Student Instructor’s signature ________________________________________________ (Instructor
MUST sign if change was made by student)
NEW test DATE: ___/___/___ TIME: _____
AM/PM until _____ AM/PM
Date received
by AC _______________________
University of Minnesota Duluth
Before your test will be rescheduled, you MUST do the following:
***This form must
be in Disabilty Services & Resources within 24 hours of the test change***
Student Name: ____________________________ Dept & Course # _________________ Check one: ______My
“To be Announced” test will be: Date: ____________ Time: ________ ______My test date/time has
been changed: OLD test DATE: ___/___/___
TIME: _____ AM/PM until _____ AM/PM This change was made by (choose one):
Instructor Student Instructor’s signature
________________________________________________ (Instructor
MUST sign if change was made by student)
NEW test DATE: ___/___/___ TIME: _____
AM/PM until _____ AM/PM