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2. Instructions
   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.
4. Person Completing This Form

   1. Qualified Citizen

   1. Representative of Citizen
6. Date
   Date
8. Qualified Citizen Contact Information
10. Name
12. Street Address
14. City
15. State
16. Zip
18. Telephone Number
19. Email Address
21. Preferred Method of Contact

    1. Email

    1. Telephone

    1. Mail
23. Representative's Contact Information
25. Representative's Name
27. Representative's Street Address
29. City
30. State
31. Zip
33. Representative's Telephone Number
34. Representative's Email Address
36. Representative's Preferred Method of Contact

    1. Email

    1. Telephone

    1. Mail
38. Request Details
40. Please identify the City department or office associated with the program, service, or activity.
    -- Select One --City Manager's OfficeCity Attorney's OfficeCity Clerk's OfficeEconomic and Community DevelopmentFireHuman ResourcesMunicipal CourtOffice of Management and BudgetParks and RecreationPolicePublic Information and EventsPublic TransportationPublic Works
42. Please specify the program, service, or activity you are seeking to participate in.
44. If you are asking for an exception to a rule, policy, or procedure, please specify which one you are seeking an exception from.
46. If you have a specific request (such as the way a department communicates with you), please explain the nature of your request.
48. What is the accommodation you are requesting?
50. How will this accommodation assist you?
52. Additional Information
54. If you would like to attach a PDF or Word Document, please attach here.
Leave This Blank:


56. 1. Receive an email copy of this form.
57. Email address

    This field is not part of the form submission.

58. Submit

* indicates a required field