Request for Reasonable Accommodation If you're a qualified individual with a disability as defined under the Americans with Disabilities Act (ADA) and you are entitled to a reasonable accommodation, you may request one. Accommodations may be requested for the following purposes: To complete the employment application process or examination To perform essential job functions To have equivalent benefits and privileges to those available to non-disabled employees To obtain evacuation assistance during an emergency Advanced notice is usually required to fulfill a request for reasonable accommodation. However, a response to a request for an immediate reasonable accommodation will be accommodated to the extent possible.Date of Accommodation Name First Last I am an:ApplicantEmployeeEmail DepartmentSelect departmentArlington Economic DevelopmentOffice of the County AttorneyCounty Board OfficeOffice of the Clerk of the Circuit CourtCounty Manager's OfficeOffice of the Commissioner of RevenueDepartment of Community Planning, Housing & DevelopmentOffice of the Commonwealth's AttorneyDepartment of Environmental ServicesDepartment of Human ServicesDepartment of Management & FinanceDepartment of Parks & RecreationDepartment of Technology ServicesFire DepartmentGeneral District CourtHuman Resources DepartmentJuvenile & Domestic Relations CourtDepartment of LibrariesOffice of the MagistrateOffice of Emergency ManagementPolice DepartmentOffice of Voter RegistrationRetirement SystemOffice of the SheriffOffice of the TreasurerJob TitleWorksite LocationSupervisor First Last Work PhoneHome PhoneDocumentation of Protected StatusExplain or attach copyAttach fileAccepted file types: pdf, doc, docx, txt.If attaching Documentation of Protected Status from above, do so here. Allowed file extensions: doc, docx, pdf, txt.I am requesting accommodation(s) for the following reason(s): To complete the employment application process, including examination. To perform essential job functions. To have equivalent benefits and privileges of non-disabled employees. To obtain evacuation assistance during an emergency. Check all that applyHow does your limitation restrict your ability to accomplish or obtain the item(s) checked above?If related to the performance of job responsibilities, state the job functions for which you need an accommodation, and describe the difficulty you have performing that task.What type of accommodation(s) do you believe would be effective? For those accommodations that must be purchased or attained, identify possible resources for the county to consider in responding to the accommodation request.SignatureI certify that the above statements and all information provided are true and correct to the best of my knowledge.NameThis field is for validation purposes and should be left unchanged.