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Accommodation Request

Americans with Disabilities Act (ADA) Accommodation Request Forms
NOTE: If your requestis for the Superior Court and not the Clerk of the Court, see http://www.superiorcourt.maricopa.gov/SuperiorCourt/AmericansWithDisabilitiesAct/Index.asp
Applicant Information *  Required Field
Applicant is: *
First Name *
Last Name *
Street Address *
Address 2  
City: *    State: *    Zip: * 
Phone: *    TDD (check if Telecommunications Device for the Deaf)
Email Address:
Please complete the following: *  Required Field
Case Number  
(if applicable)
Location: *  
1. Type of service, activity or program: *
2. Date(s) accommodations needed (specify): *
Start:       End:      Date Format: (mm/dd/yyyy)
3. Impairment necessitating accommodations (specify): *
4. Type of accommodations (be specific): *
5. Special requests or anticipated problems (specify): *

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