Petaluma Transit | Petaluma Transit Reasonable Modification Request Form

Reasonable Modification Request Form

Date*
MM slash DD slash YYYY
Name*
First Last
Phone*
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
I certify as follows:
I request a modification of the following policies, practices or procedures:
Please select one of the listed options.
If Petaluma Transit Bus Route(s), please select route(s).
- Route 2
- Route 3
- Route 10
- Route 11
- Route 24
- Route 33
If Other, please describe the policy or procedure.
I request the following reasonable modification be made to the policy, practice or procedure identified above (describe modification requested):
Without the modification, I would be unable to fully use Petaluma Transit or Petaluma Paratransit services and activities because:
I understand that Petaluma Transit is not required to modify its services to provide personal care attendants, service animal supervision, medical services, service outside its service area or hours of operation, modifications which would cause a direct threat to the safety of others, modifications which would cause a fundamental alteration of its service, modifications that would impose an undue administrative or financial burden on Petaluma Transit or Petaluma Paratransit, and modifications which would result in an illegal act.*
- I agree.
My preferred method of contact regarding this request:*
Electronic Signature
Electronic Signature*

Please type First and Last name
Date*
MM slash DD slash YYYY
I understand that checking this box constitutes a legal signature confirming that I acknowledge the truthfulness of the information provided.*
- I agree

Petaluma Transit Reasonable Modification Request Form

Reasonable Modification Request Form

I certify as follows:

Electronic Signature