Form Builder - City of Burlington

Required fields are marked with asterisks (*)

Accessible Formats and Communication Support Request

Purpose
Please use this form to submit a request for an accessible format / communication support.

Notice of Collection
Personal information contained on this form is collected under the authority of the Municipal Act, 2001, S.O. 2001, c. 25 and will be used for the purposes of administering your request for, and use of, Accessible Formats and Communication Support request. Questions about the collection of personal information should be directed to the Accessibility Coordinator at judi.lytle@burlington.ca

First Name

Last Name

E-mail Address

Daytime Phone Number

Extension

Evening Phone

Address

City

Province/State

Postal/Zip Code

Please enter the document name or details

Name of department or business area if known

If the document is on our website please copy and paste the document address

Please select the format or communication support you prefer

Accessible PDF

Braille

Large Print

Microsoft Word

Rich Text

American Sign Language (ASL)

Real Time Captioning (CART)

Other

Please tell us by what date you require this information.

Please provide any additional information that will help us to accomodate your request.