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Americans with Disabilities Act Action Request Form - Employees or Applicants

Please correct the field(s) marked in red below:

Contact:

Human Resources Director
777 Lynn Street 
Herndon, Virginia 20170

If you prefer a non-written format to submit a request or complaint, please call 703-435-6817.

1
Please check one of the following:
Please check one of the following:
2

3

Description of Problem

Please give a detailed description (including names/telephone numbers of any witnesses if reporting a problem).

4

Describe Your Accommodation Request

Please be as specific as possible.

5

Typing your name in the space below serves as your electronic signature.

Typing your name in the space below serves as your electronic signature.
  1. To receive a copy of your submission, please fill out your email address below and submit.