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
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
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