STATE PE
RSONNEL SYSTEM
For the purpose of this preference, INDIVIDUAL WITH A DISABILITY means anyone who has
a physical or mental impairment which substantially limits one or more of their major life
functions, or has a record of such impairment or is regarded as having such impairment.
Preference will be awarded ONLY upon the Arizona Department of Administration
Human Resources Information Solutions' (HRIS) receipt of this signed and dated "Request
for Disability Preference" form. The completed form is intended for use solely in connection
with A.R.S. 38-492. The information is requested on a voluntary basis and will be kept
confidential. Refusal to provide the requested information will not result in adverse treatment.
Requests for reasonable accommodation in the interview/testing process should be made
directly to the hiring agency when they contact you.
Once you have completed this form, please email the form to the HRIS Help Desk at
hrishelpdesk@azdoa.gov.
You may also print the form and fax it to 602-542-4745.
or mail the form to:
Arizona Department of Administration
ASET - HRIS Help Desk
100 N. 15th Avenue, Suite 400
Phoenix, Arizona 85007
I hereby request preference. I affirm/certify that I meet the above definition of an INDIVIDUAL WITH
A DISABILITY, and am eligible for preference.
First
Last
M.I.
Name
Name
Street
Address
State
City
Daytime Phone
Zip Code
Number
Signature
Date
ASPS/HRD-FA3.17 2/19
Arizona State Personnel System Request for Disability Preference
click to sign
signature
click to edit
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