Fillable Form 12415 (City of El Mirage)

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Form 12415 (City of El Mirage)

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The Form 12415 (City of El Mirage) form is 1 page long and contains:

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Country of origin: US
File type: PDF

U.S.A. forms for City of El Mirage

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Human Resources
10000 N. El Mirage Road, El Mirage AZ 85335
623-876-2949; Fax 623-876-4604; TDD 623-933-3258
www.elmirageaz.gov
HR USE ONLY
ACTION DATE:
INITIALS:
CITY OF EL MIRAGE
REQUEST FOR ACCOMMODATION
DATE:
NAME: ADDRESS:
PHONE: CITY:
EMAIL: ZIP CODE:
RECRUITMENT NO. / POSITION TITLE AFFECTED:
DATE DESIRED (if applicable):
DESCRIPTION OF ACCOMMODATION REQUESTED:
NATURE OF DISABILITY:
I hereby request the above accommodation and affirm that I am a qualified individual with a disability
pursuant to the Americans with Disabilities Act.
____________________________________________ _____________________________
Signature Date
Please note that a certification of disability from a Physician may be requested.
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Form 12415 (City of El Mirage)

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Completed 15 July 2020

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