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2. Reasonable Modification Request Form
4. A public accommodation shall make reasonable modifications in policies, practices, or procedures, when the modifications are necessary to afford goods, services, facilities, privileges, advantages, or accommodations to individuals with disabilities, unless the public accommodation can demonstrate that making the modifications would fundamentally alter the nature of the goods, services, facilities, privileges, advantages, or accommodations.
6. Date
   Date

   Date
7. ADA Coordinator | Phone: 318- 673-5541

    Office Location:  505 Travis St.  Suite 620 – Shreveport, LA. 71101

9. First Name
10. Last Name
12. Address2
14. City
15. State
    -- Select One --ALAKAZCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNUTVTVAWAWVWIWYDC
16. Zip
17. Your Phone Number
19. Your Email Address
21. How would you like us to contact you?
23. Email

    1. Email
24. Postal Mail

    1. Postal Mail
25. Telephone

    1. Telephone
26. Other
28. Please describe the requested modification and provide any supporting documentation necessary to assist in processing the request.
30. Please sign and date this request. You do not need to sign if submitting form by email, just type your name where it list Signature.

    Parent or Legal Guardian may sign on behalf of a minor child.  |   Legal Guardian, Power of Attorney, or equivalent may sign on behalf of adult, documentation is required. 

31. Who is this request for (Select One)
    -- Select One --YourselfA Minor ChildBehalf of Disabled Adult (not yourself)
33. Self

    1. Self
34. Parent

    1. Parent
35. Legal Guardian

    1. Legal Guardian
36. Power of Attorney

    1. Power of Attorney
38. Signature
39. Date Signed
    Date Signed

    Date Signed
41. Upload Relevant Document(s)
Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit

* indicates a required field