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2. The City of Holland is committed to compliance with the Americans with Disabilities Act (ADA) to ensure that persons with disabilities have equal and full access to city government services. This form may be used to request a reasonable modification to the accessibility of a city service. Forms must be received at least 7 days before the event for which an accessibility modification is needed, so that we have time to properly honor your request.

6. First Name
7. Last Name
9. Address
11. City
12. State
13. Zip Code
15. Phone Number
17. Email Address
19. Preferred Contact Method
    -- Select One --PhoneEmail
21. Program, Service, or Event for the Request
23. Location of the Program, Service, or Event
25. Date and Time of the Program, Service, or Event
    Date and Time of the Program, Service, or Event

    Date and Time of the Program, Service, or Event
27. Accommodation or Modification You Are Requesting
    -- Select One --ASL Interpretation ServicesModification of Policy or Procedure (Describe Below)Accessible Formats such as large print, Braille, electronic document, or audio tapesQualified ReadersOther (Describe Below)
29. Description, Explanation, Comments
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field