CISCO CAREER CERTIFICATION EXTENSION REQUEST COMPLETE ALL INFORMATION. MAKE SURE THAT ALL SECTIONS ARE COMPLETE BEFORE YOU SUBMIT THE FORM SECTION 1: CANDIDATE'S IDENTIFYING INFORMATION: To be completed by candidate By completing this form, you acknowledge Cisco is collecting your personal information for the purpose of determining the validity of this request and you provide your consent to do so. First Name: NADEERA LastName: HASMA cscoecte wD: C$ CO 11226323 [24310 pagbicsa Poe pate: __23 -O%- 2022 Candidate's Signature: SECTION 2: To be completed by professional diagnostician Name of Diagnosing Professional: DR. SHekK HOR a Karnatate, License Number: 2|30€ expiration Date: 1 J____ Issuing State/Province/Territory:___ Phone Number: FILOF SELL email: Bure saomicges ui | Coy, 1, hereby attest that thisrequest from the above-mentioned (Print Diagnosing Professiona’s Name) candidate for extension and/or accommodation is valid and warranted. Diagnosing Professional's Signature: vate: 23109 20% Cisco protects your privacy.For additional information, please read, BNI Dr SHEKHAR \ 452, 2 0058 +e physician Hoyaga tara Gate Fst Family Phy: ve (Sateen, 1780 reg. No. 21308 eine Wear one