BELGRADE COMMUNITY LIBRARY

106 N BROADWAY

BELGRADE, MT 59714

388-4346

www.belgradelibrary.org

 

AMERICANS WITH DISABILITIES ACT

 

REASONABLE ACCOMMODATION REQUEST FORM

(Please Print.  You may use separate sheets of paper if you need more space)

 

NAME:_______________________________________________________________________

 

ADDRESS:____________________________________________________________________

 

CITY, STATE, ZIP:_____________________________________________________________

 

TELEPHONE (INCLUDE AREA CODE):___________________________________________

 

 

What service, program or activity does this request concern?

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Date (if applicable): _____________________________________________________________

 

What accommodation is requested? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

Signature______________________________________Date__________________________

 

You may call the Library Director if you would like help in filling out this form 406-388-4346

Please return the completed form to the Belgrade Community Library Director