YOUR INFORMATION |
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Your Name |
Your Disability |
Your
Mobility Aid |
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Spouse Name |
Spouse Disability |
Spouse
Mobility Aid |
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Child Name |
Child Disability |
Child
Mobility Aid |
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Primary Phone |
Alternate Phone |
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E-Mail |
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Street Address |
Mailing Address
(if different)
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Houston
ZIP Code |
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ACCESSIBILITY LOCATION(S) INFORMATION
- Please give as much information about location as possible -- exact address, landmark, hundred block, intersection, etc.. EXAMPLE: From 100 to 200 block of Jackson Street, or 215 Jackson, or the corner of Jackson @ Alberta, etc.
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FIRST LOCATION |
SECOND LOCATION |
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First Location Condition |
Second Location Condition |
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First Location Site Info |
Second Location Site Info |
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ADDITIONAL ROUTE INFORMATION
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When I walk out of my door, I walk down the walkway and turn ...
... where the walkway meets the sidewalk and go ...
... when I encounter the condition shown above. |
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When I leave my home, my destination is ...
. I have to ...
... to get to my destination. I have no alternative path of travel. |
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COMMENTS OR CONCERNS |
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Public Works ID#
(if applicable) |
How did you hear about our office? |