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Fill and Sign the Form 14cr004e Ada 2 Request for Reasonable Accomodation

Fill and Sign the Form 14cr004e Ada 2 Request for Reasonable Accomodation

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14CR004E-001 OKLAHOMADEPARTMENT OF HUMAN SERVICES Request for Reasonable Accommodation Client or Applicant for Services Please Print Name of Client or Applicant: Case Number: Social Security Number: Address: Telephone (work): (home): List the DHS services you are requesting or currently receiving that require this accommodation: Disability to be accommodated: Requested Accommodation: Is medical documentation attached? Yes No If no, give reason: Employee Signature Date ADA Coordinator Signature Date Division Administrator, Associat e Director, Area Director Signature Date Return Original To: Office for Civil Rights P.O. Box 25352 Oklahoma City, OK 73125-9975 OKDHS issued 5-20-1998 14CR004E (ADA-2)

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The best way to complete and sign your form 14cr004e ada 2 request for reasonable accomodation

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