Request for Accommodation

1

For which type of activity or function is an accommodation being requested?* This field is required.

Commission Meeting

Application or Hiring Process

Service/Program/Activity/Other

2

Date of meeting* This field is required.

Date

3

Location of meeting* This field is required.

4

Date of Service/Program/Activity/Other* This field is required.

Date

5

Position Title* This field is required.

6

Assistance requested with:* This field is required.Check all that apply

Application

Testing

Interview

7

Describe the specific limitation and the type of accommodation requested, with an explanation of how the accommodation will assist in completing or participating in the activity.* This field is required.Note: Verification of the disability by the requestor's healthcare provider may be required.

8

Name of person requesting the accommodation* This field is required.

First Name

Last Name

9

Phone Number* This field is required.

Please enter a valid phone number

10

Email* This field is required.

example@example.com

11

Address* This field is required.

Street Address

Street Address Line 2

City

State

Zip Code

Country

12

Preferred method of contact

Phone

Email

Postal Mail

13

Acknowledgement:* This field is required.

I declare under penalty of perjury under the laws of the State of Washington the foregoing is true and correct

14

Please verify that you are human* This field is required.