ADA Request for Reasonable Accommodation Form

Person Completing this form:*
First Last
Check One:
- Citizen
- Representative of Citizen
Accommodation Information
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Email*
Preferred Method of Contact*
- Email
- Telephone
- Mail
Accommodation Information
Please identify the town department or office associated with the program, service, or activity:
Accommodation you are requesting:
Please identify the town department or office associated with the program, service, or activity:
How will this accommodation assist you?

Accommodation Information