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Accessible Curb Ramp Request Form
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Please complete the following form or download a printable version
Click here to download the Accessible Curb Ramp Request Form
REQUESTOR'S INFORMATION
Name:
Date:
Address:
City:
State:
Zip:
Telephone:
Email Address:
CURB RAMP LOCATION(S)
Street Intersection
Corner Location for Request (e.g., NW corner):
REQUEST DETAILS
1. Are you a person with mobility and/or vision disabilities?
Yes
No
If yes, explain
2. Are the pedestrian routes from the intersection serving State and local government offices and facilities (includes parks)?
Yes
No
If yes, explain
3. Are the pedestrian routes serving important transportation corridors, including pathways leading to schools?
Yes
No
If yes, explain
4. Are the pedestrian routes serving commercial/business zones and other Title III entities (private entities open to the public) e.g., restaurants, hotels, theaters, retail stores, shopping centers, grocery stores, hospitals, medical offices, law offices?
Yes
No
If yes, explain
5. Are the pedestrian routes serving facilities containing employees?
Yes
No
If yes, explain
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