ADA Reasonable Modification Request Form

Instructions for ADA Reasonable Modification Request

Please fill out this form completely, sign and mail, fax, or email to:

Gladwin City County Transit ADA Coordinator
615 Weaver Court
Gladwin, MI 48624
989-426-5947 Fax
kim@gladwintransit.com

"*" indicates required fields

Rider:*

First Last

Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Telephone:

Mobile Phone:

Email:*

Person requesting modification (if other than the rider):

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Telephone:

Mobile Phone:

Email:

Describe the rider’s disability or disabilities.*

Describe the service policy or program that may need to be modified to allow the rider full access to the transit services provided.*

How does the current service policy or program prevent the rider from using the transit service or program?*

Please describe the specific modification to the current policy/procedure that you are requesting*

How would you like (transit agency) to respond to your request?*

In writing to the address listed above

By email to the address listed above

Other

If future communications regarding this request are needed in an alternate format, please indicate the appropriate format below:

Spanish

Large print (font size needed.)

List font size for large font request:

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