For more Accessibility/ADA information, please see our accessibility web page. If you have any questions or need additional assistance with this request form, please contact Human Resources at 775-334-2285.

Personal Information:

 *

Personal Information:

Name (First and Last)	Street Address
City	State
Zip Code	Phone Numberext.
Cell phone (alternate phone)ext.	Email address
Preferred method of contact

Accommodation Information

Please select all accommodation requests that apply.

 

I am requesting an accommodation that will allow me to participate in a program or activity offered by the City.

 

Please specify the department, program, service or activity:

 

I am requesting an accommodation by asking for an exception to a rule, policy or procedure.

 

Please specify the rule, policy or procedure:

 

Other accommodation:

 

Please specify other accommodation:

 

Describe the accommodation that you are requesting, as well as list as many alternative modifications that you can think of:

Describe how this accommodation will assist you.

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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