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This form is to be used by City employees and job applicants seeking a reasonable accommodation relating to their employment or application for employment pursuant to the Americans with Disabilities Act (Title I) and/or Section 504 of the Rehabilitation Act of 1973. The City is committed to equal opportunity in all aspects of employment for qualified disabled individuals. Information regarding the City’s ADA policy is also available on the City's website.
ADA Co-Coordinator and Human Resources Assistant Director
City of Murfreesboro
111 West Vine StreetMurfreesboro, TN 37130
Telephone: (615) 848-2553 Facsimile: (615) 904-6506 Email: email@example.com
(Note: The City may require additional information to evaluate this request and may ask that you submit a statement or other medical documentation from your healthcare provider.)
(If the accommodation is a device or other item that can be purchased, please identify the item’s manufacturer, model number, and price and how the item can be purchased.)
I certify that I have a disability that requires reasonable accommodation and that the information I have provided on this form is accurate and complete to the best of my knowledge.
This field is not part of the form submission.
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