Disability Accommodation Request

You may request an accommodation for a City of Benicia program, service, activity, on behalf of yourself or a person with a disability. Please complete the fields to the best of your ability, there is no requirement to fill in all the fields to submit the form. Please submit your request at least four working days before a scheduled event unless otherwise specified on a published agenda (such as that of a Board, Commission or City Council). We will do our best to accommodate requests with fewer than four working days' notice.

Name *

Address *

Email Address or Phone Number *

Preferred contact method * Email
Phone (voice)
Phone (text)

I am making this request on behalf of * Myself
An individual with a disability to needs an accommodation.

Please provide name and contact information for person(s) affected, if other than requestor:

Please describe the accommodation you are requesting. Provide as much detail as possible, including the date and location of the program, service or activity.

Description of request: *

If you have questions, please contact the ADA Coordinator at:

Suzanne Thorsen, Assistant City Manager/ADA Coordinator
Phone: 707-746-4200
To use the California Relay Services (CRS), dial 711
adacoordinator@ci.benicia.ca.us

* - denotes required field