TITLE II AMERICANS WITH DISABILITIES ACT REQUEST FOR REASONABLE ACCOMMODATION FORM

Instructions: If you or someone you know requires auxiliary aids and/or services to participate in City of Buffalo sponsored programs, services, or activities, then please complete this form. Required fields are in BOLD.

The City of Buffalo does not charge a fee for providing auxiliary aids and/or services to enable someone with a disability to participate in a City of Buffalo program, service, or activity.

The Americans with Disabilities Act does not require the City of Buffalo to take any action that would fundamentally alter the nature of its programs, services, or activities, or impose an undue financial or administrative burden.

PLEASE NOTE: You cannot save a completed copy of this form on your computer. If you would like a copy for your records, please complete the form and then print the form before clicking the save button at the bottom of the page.

THIS FORM MUST BE SUBMITTED AT LEAST FIVE (5) WORKING DAYS PRIOR TO THE PROGRAM, SERVICE, OR ACTIVITY TO ENSURE ACCOMMODATION.

PERSON WHO REQUIRES ACCOMMODATION:

Prefix:
First Name:
Last Name:
Address1:
Address2:
City:
State:
Zip Code:
Telephone Home:
Telephone Work:

What is the nature of your disability and how does it limit one or more major life activities?

Nature of Disability:

INDIVIDUAL COMPLETING FORM:
(Complete ONLY if the form is being completed by a person other than the individual requiring accommodation)

Prefix:
First Name:
Last Name:
Title:
Firm:
Address1:
Address2:
City:
State:
Zip Code:
Telephone Home:
Telephone Work:

Please describe the accomodation that you are requesting:

Describe Accommodation:

What is the name of the City of Buffalo Department responsible for the program, activity, or service?

Department Name:

What is the name of the program, activity, or service?

Program Name:

Is the program, activity, or service taking place on a specific date and time? If so, please specify where and when.

Description:
Additional Space:

Your electronic signature verification below certifies that the information you provided in this form is complete and accurate to the best of your knowledge and constitutes your signature as if actually signed by you in writing. Please be aware that an electronic signature is as legally binding as a handwritten signature.

ESignature