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If you were unable to graduate, seek licensure and/or secure employment due to either local or State restrictions or for other reasons associated with the COVID-19 Pandemic please complete the following form.
Student Full Name
As of November 30, 2023, please state the reason you should be exempt.
Graduation: I withdrew (dropped) from school for reasons related to COVID-19.
Licensure: I did not test for reasons related to COVID-19, or I previously sat for all parts of the exam and failed one or more portions of the licensure exam and attests in writing that I elected not to retest for reasons related to COVID-19.
Placement: I elected not to pursue employment within my field of study for reasons related to COVID-19, or was unwilling to obtain licensure for reasons related to COVID-19, or (iii) I was unable to secure employment as employers were closed or had limited capacity for reasons related to COVID-19.
I understand that my signature certifies and affirms that the information provided by me is true and correct to the best of my knowledge.I understand that my electronic signature shall have the same force and effect as my written signature.
Please upload a copy your current photo ID (e.g. passport, driver’s license, green card)
Max. file size: 100 MB.
This field is for validation purposes and should be left unchanged.