CITY OF COOKEVILLE
Gail Fowler, ADA/504 Coordinator
45 East Broad Street
Cookeville, TN 38501
Phone: 931-520-5256
Tennessee Relay: 7-1-1
gfowler@cookeville-tn.gov
REQUEST FOR ACCOMMODATION OR BARRIER REMOVAL
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The City of Cookeville ensures that no person or groups of persons shall, on the grounds of race, color, sex, religion, national origin, age,
disability, or genetic information, be
excluded from participation in
,
be denied the benefits of, or be otherwise subjected to discrimination
under any and all programs, services, or activities administered, its recipients, sub-
recipients, and contractors. To request an
accommodation and/or
an
alternate format, please contact Gail
Fowler, ADA/504 Coordinator at 931 520 5256, or Tennessee Relay by
dialing
7 1 1.
Check one: Accommodation Barrier Removal
Name of Complainant: ________________________________________________________________
Last First M
Address: ___________________________________________________________________________
City: _______________________________ State: _____________________ Zip: _______________
Telephone Number: _______________________ E-mail Address: ____________________________
Preferred Method(s) of Communication: (Check all that apply)
Voice Telephone TTY E-mail US Mail & Other: ___________________________
Accommodation needed or location of barrier:
Brief statement of why the accommodation is needed or the barrier removed:
NOTE: Barrier Removal requests are reviewed and prioritized by the City with regard to budget and
scheduled projects.
Date accommodation is needed: ________________________________
___________________________________________________________________________________
CERTIFICATION: I hereby certify that the information and statements above are true.
Signature: ___________________________________________________ Date: _________________
If person needing accommodation is not the individual completing this form, please provide
click to sign
signature
click to edit
Representative’s Name: _______________________________________________________________
Address: ________________________________________ Telephone Number: _________________
____________________________________________________________________________________
For more information or assistance in completing this form, please contact:
Gail Fowler, ADA/504 Coordinator
45 East Broad Street
Cookeville, TN 38501
Phone: 931-520-5256
Tennessee Relay: 7-1-1
gfowler@cookeville-tn.gov
The City of Cookeville will not place a surcharge on a particular individual with a disability or any group
of individuals with disabilities to cover the cost of providing auxiliary aids/services or reasonable
modifications of policy, such as retrieving items from locations that are open to the public but are not
accessible to persons who use wheelchairs.
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