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Reasonable Accommodations Attachment # I — page 5 of '5 <br />I affirm under penalty of perjury that the information provided in this application is true <br />and accurate. I understand that providing false or misleading information will result in a denial of <br />my application. <br />To the extent this Application contains any information protected by the Health Insurance Portability and <br />Accountability Act of 1996 (HIPPA), I do not waive my rights under HIPAA. <br />Printed name: <br />Signature: <br />Date: <br />15 <br />