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As a student of the University of North Texas Health Science Center (UNT Health Science Center) and an individual claiming to have a permanent disability (hereinafter referred to as “disability”), I hereby designate the Office of Disability Access (ODA) to be the holder of record for documentation of my disability and request that accommodations which are appropriate to my disability, and reasonable in the context of the academic and student service environment under the American with Disabilities Act (ADA), be provided to me by applicable entities at the UNT Health Science Center. This form is intended to be used in gathering information and in conjunction with required documentation. Completing this form does not guarantee accommodations and will not be considered if documentation is not submitted.