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REQUEST FOR THE INSTALLATION OF ACCESSIBLE PEDESTRIAN SIGNALS FORM
Requesting Party‟s Name:
______
______________________________________________________________________________
(Blind or visually impaired pedestrian)
Address: ______________________________________________City:__________________________
State: _________Zip Code: ________
Telephone (Home): _______________________ Telephone (Work): ______________________
I request that the Delaware Department of Transportation install Accessible Pedestrian Signals (APS) to
cross the NORTH SOUTH EAST WEST (check all that apply) side of
_________________________________________________________(Route Number/Street Name)
where it crosses ___________________________________________ (Route Number/Street Name) in
_________________________________________________________ (city, town, or county).
Please describe the difficulty you have in crossing:
P.O. Box 778
Please call DelDOT at 1-302-760-2048 with questions, or to seek assistance in filling
out the form and/or mail form to:
DelDOT ADA Title II/Section 504 Coordinator
ATTN:
Todd Webb
Dover, DE 19903
E-mail: DOT.ADARequest@state.de.us
For Office Use Only
Date Rec
eived: __________________ Received by: ___________________________________
