-- For further assistance, if information is needed in another language, if you need assistance in completing this form, need the form in an alternative format (such as a larger font), or need to submit the form in an alternative format (such as a personal interview or by audio recording).
-- If you are deaf or hard of hearing and are requesting an interpreter, please specify the type of interpreter (i.e., American Sign Language (ASL), signed English, Communication Access Real Time Translation (CART), or other) when describing the accommodations you are requesting.
-- If you do not want to send an electronic request, contact the Title VI Coordinator, or submit the information in writing via US Postal Service to the Mid-Region Council of Governments, 809 Copper Avenue NW, Albuquerque, NM 87102.
Sandra Gaiser, Title VI Coordinator, at 505-247-1750 or firstname.lastname@example.org.
Pease provide any additional details necessary to process this request. Describe the accommodation(s) needed or location of barrier. Include a brief statement of your functional limitations, why the accommodation is necessary, and how this will enable you to participate in our services, programs or activities. Be as specific as possible and provide any additional information that might be useful in reviewing your accommodation request.
I certify that the statements provided in this request form are true, accurate and complete.
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