Request for Accomodation Modification Form

ACCOMODATION/MODIFICATION
REQUEST FORM 

Use this form to request a modification of Citrus County Transit Policies or procedures. Be specific and provide as much detailed information as possible. This will allow us to effectively process and evaluate your request. Before filling out this form please review Citrus County Transit’s Reasonable Accommodation/Modification Procedures.

 Name: __________________________________________________________________ 

Date of the trip:_____________________________ 

Phone number: ____________________________ 

Street Address & Apt. No.:________________________________________________________ 

City:______________________ State: _____________________ Zip:_____________________ 

Based on your disability, why is the modification necessary?_____________________________ 

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 Modification

Provide a description of your need and how it is affected by Citrus County Transit’s policies/procedures.: 

_____________________________________________________________________________________________________________________

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 Signature: ___________________________________________  Date:____________________

Once completed, please send this form to:     Citrus County Transit
                                                                        1300 S. Lecanto Hwy.
                                                                        Lecanto, FL 34461 

All the information involved with this process will be kept confidential.