ADA Title II Request for Reasonable Accommodation Form

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If you are completing this form for another individual, please submit their contact information and the preferred method of contact. If you are the person who we should contact, please submit your information and your preferred method of contact.

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Person Completing This Form

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Citizen

Representative of Citizen

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Today's Date

MonthDay Year,

Citizen Contact Information:

Name

Address

City

State

ZIP

Zip-Zip +4
Second portion of ZIP Code is optional.

Telephone

Phone Area Code-Phone 3-Phone 4 ext Extension

Email Address

Preferred Method of Contact

Telephone

Mail

Representative of Citizen Contact Information:

Name

Address

City

State

ZIP

Zip-Zip +4
Second portion of ZIP Code is optional.

Telephone

Phone Area Code-Phone 3-Phone 4 ext Extension

Email Address

Preferred Method of Contact

Telephone

Mail

Accommodation Information:

Please identify the City department or office associated with the program, service, or activity:

Please specify the program, service or activity you are seeking to participate:

Accommodation you are requesting

How will this accommodation assist you?

Please include additional information here:

ADA Title II Request for Reasonable Accommodation Form

Citizen Contact Information:

Representative of Citizen Contact Information:

Accommodation Information:

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