ADA Accommodation Request Form

American with Disabilities Act (ADA) Form

Please provide the following information necessary to process your ADA accommodation request. Complete, sign and return this form by mail, FAX or email to:

ADA Coordinator
Ada County Department of Administration
200 W Front Street, Boise, ID 83702
Phone: (208) 287-7123
FAX: (208) 287-7159
[email protected]
Date*
MM slash DD slash YYYY
Requestor's Name*
Address*
Street Address City State ZIP Code
Phone (Home)*
Phone (Work)
Email*
Program, service or activity requiring accommodation*
Date and time when accommodation was needed*
Location where accommodation in needed*
Please describe why you need an accommodation and the type of accommodation you are requesting*
I certify that to the best of my knowledge and belief that the statements and information on this form are true, accurate and complete.
Requestor's Signature (Please type you full name)*
Date*
MM slash DD slash YYYY