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Request for Accommodation or Barrier Removal Form
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ONEKingsport
Podcast: From the City Desk
Agendas & Minutes
Board of Mayor and Aldermen
BMA Meeting Schedule
City Budget
Comments or Questions
Finance
News
Closing & Delays
Highlighting Heroes: People Behind the Service
Newsletter Subscription
Notices and Outages
ONEKingsport
Podcast: From the City Desk
Request for Accommodation or Barrier Removal
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:
*
Date Format: 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:
*
Date Format: 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.
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