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2. The City of Pensacola is committed to compliance with the Americans with Disabilities Act (ADA) in all aspects of providing equal access to all city-sponsored programs and events and does not discriminate on the basis of disability in the city’s services, programs or activities. This form may be used by citizens to request a reasonable modification to the accessibility of a city program, service or facility. Please submit the form no later than 72 hours before the event for which an accessibility modification is needed in order for us to honor your request.
4. Required fields are marked with an asterick *
6. Your Name*
8. Email Address*
10. Address
12. City
13. State
14. Zip
16. Daytime or Cell Phone
18. Program, service or event for the request*
20. Location of program, service or event*
22. Date of program, service or event (Enter as MM/DD/YYYY)*
24. I am requesting the following accommodation or modification. * *

    Please click on one or more listed options.

    1. Wheelchair Access
    2. ASL Interpretation Services
    3. Printed Material in Alternate Format
    4. Modification of Policy or Procedures
    5. Printed Material (Please indicate desired format type below)
    6. Other (Please describe below)
26. If you selected "Printed Material" as your accommodation or modification, in the previous question, please describe the material and desired format type:
    (Please provide a week advance notice for requests of printed materials in Braille.)
28. If you selected "Other" as your accommodation or modification, in the previous question, please describe your request:
30. Please provide any additional details necessary to process this request:
32. All records, forms and communications submitted to the City of Pensacola pertaining to official business will be subject to disclosure under the Florida Public Records Law, unless they are defined by the law as exempt or confidential.
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34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit Submit and Print

* indicates a required field