Request for Accommodation or Barrier Removal Form

Per the ADA, form is required in regards to a request for Accommodation or Barrier Removal

Check One:*
- Accommodation
- Barrier Removal
Name of Complainant:*
First Last
Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone:*
Email:*
Preferred Method of Contact:*
- Voice Telephone
- TTY
- CRS
- Email
- US Mail
Accommodation needed or location of barrier:*
Brief statement of why accommodation is needed or the barrier removed:*
Date accommodation is needed:*
MM slash DD slash YYYY
Signature*
Certification: I certify that I have a disability or medical condition that required reasonable accommodation, which will be met by acquiring the equipment, services or work adjustments described above.
Date:*
MM slash DD slash YYYY
If person needed accommodation is not the individual completing this form, please provide a representative’s name, address and telephone number:
Comments
This field is for validation purposes and should be left unchanged.