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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

If yes, explain

2. Are the pedestrian routes from the intersection serving State and local government offices and facilities (includes parks)?

Yes

If yes, explain

3. Are the pedestrian routes serving important transportation corridors, including pathways leading to schools?

Yes

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

If yes, explain

5. Are the pedestrian routes serving facilities containing employees?

Yes

If yes, explain