ATTACHMENT A
CITY OF FORT BRAGG
REASONABLE ACCOMMODATION REQUEST FORM
Name _____________________________________________________________________________ Name of Person Requesting Accommodation
Address ____________________________________________________________________________ Street City State Zip Code Telephone _____________________________ Email ______________________________________ I am requesting accommodation to participate in the following City public meeting:
My specific functional limitation is:
_____________________________________________________________________________________ The accommodation I am requesting is:
_____________________________________________________________________________________ Describe how the accommodation will assist you. Please attach additional pages if necessary. __________________________________________________________________________________
REQUESTOR CERTIFICATION
I CERTIFY THAT I HAVE A DISABILITY THAT REQUIRES REASONABLE ACCOMMODATION, WHICH WILL BE MET AS DESCRIBED ABOVE.
Signature: ____________________________________________________________________________ Date