First Name
Last Name
EXIN ID
Date of Birth
Address
Phone Number
Email Address
For which exam are you requesting accommodations?
Pearson VUE and EXIN are committed to ensuring access to EXIN exams for all individuals.
To request a separate room accommodation, please complete the
Accommodation
Request
and the Declaration .
EXIN allows a 15-minute time extension if a candidate is taking an exam in a language that is not their native language. To apply for the time extension, please review the
requirements, complete the Time Extension Request
and the Declaration .

EXIN offers a separate room accommodation. To apply, please complete the sections below and sign the declaration.
Accommodation(s):
Separate Room
Rationale:
Please note: a.
You MUST NOT schedule your test until the accommodation has been reviewed. b.
An Accommodation Request Form MUST be completed each time you take an exam, this includes re-takes. c.
Each accommodation is considered on a case-by-case basis.

One of the following conditions must be met to qualify for a 15 minute time extension:
1.
The exam is not available in your native language.
2.
For a medical reason; this will be considered on a case-by-case basis.
What is your country of residence?
What is your native language?
What is your country of origin?
Rationale:
Please note: d.
You MUST NOT schedule your test until the accommodation has been reviewed. e.
If your rationale is for medical purposes, you MUST provide medical evidence (e.g. doctor’s note) f.
A Time Extension Request Form MUST be completed each time you take an exam, this includes re-takes.

I hereby state that the information provided in this document is accurate and honest to the best of my knowledge.
By signing this declaration, I provide Pearson VUE permission to share the information in this form and any supporting documentation with EXIN.
Candidate Signature:
Date:
If you are under 18, a parent or guardian must also sign.
Parent/ Guardian Signature:
Date:
Please email this form, a photocopy of your ID and any other supporting documentation (i.e. doctor’s note) to PVUKProgrammeCo-ordinators@Pearson.com
for the attention of an EXIN Programme Coordinator and wait to be contacted before you schedule your exam.