Nassau County, NY

Americans with Disabilities Act (ADA) , Title II Resolution Request Form

Contact Information

First Name: *

Last Name: *

Address 1: *

Address 2: *

City: *

State: *

Zip Code:*

Phone Number: *

Email Address: *

Name and location of service, program and or activity not fully available or accessible: *

Explain manner of which service, program or activity is not fully accessible Include photos if possible: *

Accommodation / Remedy sought: *

All fields marked with a red asterisk (*) are required