subject_line
Request for Auxiliary Aids/Services or Barrier Removal
Name of Individual Needing Auxiliary Aids/Services or Barrier Removal
Contact First Name
*
Contact Last Name
*
Email Address
*
Phone Number
*
Street or Mailing Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Name of Person Filling Out Form (If different from above)
Contact First Name
Contact Last Name
Email Address:
Phone Number
Street or Mailing Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
Relationship to person requesting auxiliary aid/barrier removal
Specifics of request:
Please identify the PPWFC facility, program, service, event, or location for which you are requesting an auxiliary aid/service or barrier removal:
*
What is the specific auxiliary aid/service or barrier removal you are requesting?
*
Additional comments and/or relevant information:
Date(s) the Auxiliary Aid/Service or Barrier Removal is Needed:
*
Time(s) or timeframe that the Auxiliary Aid/Service or Barrier Removal is Needed:
*
On receipt of this request, it may take up to 24 hours for us to meet your request. Please call (719) 667-3700 with questions.