Reasonable Accommodation

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					                                 REQUEST FOR REASONABLE ACCOMMODATION


Reasonable accommodations do not confer special treatment or advantage for the person(s) requesting
the accommodation. Rather they make the program fully accessible in a way that would otherwise not
be possible for person(s) due to their disability.

I, ______________________________________, do hereby request HOM, Inc. to grant me a
reasonable accommodation.

Accommodation Requested:




Are you disabled?                                                  Yes             No

Is your request related to your disability?                        Yes             No

How is your request related to your disability?




Applicant / Participant Signature                                             Date

                                                                                          
                                        TO BE COMPLETED BY HOM, INC.

Accommodation is               approved        or         disapproved

If disapproved, reason why:




HOM, Inc. Representative Signature                                            Date



                                          rd
                                3829 North 3 Street Suite 101 Phoenix AZ 85012-2088
            Office: (602) 265-4640  Toll Free: 1-877-HOMINC1  Fax: (602) 265-4680  www.hominc.com

				
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posted:9/19/2012
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