Microsoft Word - ADA Applicant Accommodation Request …
HR 11/1/2015
Americans with Disabilities Act (ADA)
Applicant Accommodation Request Form
Applicant’s Name: Date:
Position for which you are applying:
1. Describe how your condition affects your ability to perform a major life activity. Which major life activity(s) is/are most significantly affected? Examples of major life activities are: seeing, hearing, breathing, walking, smelling, caring for yourself, thinking, concentrating, or working.
2. Describe how your condition limits your ability to complete the application process.
3. Describe the accommodation you are requesting. Be as specific as possible.
4. Explain how the accommodations you are requesting will enable you to complete the application process. Be specific.
5. Will you be able to complete the application process if you receive the requested accommodation? If not, describe the specific functions you will not be able to perform.
6. Is there any other information that would help us evaluate your request? If yes, please explain.
Applicant Signature Date
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