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Application to Request Reasonable Accommodation of a Disability Fire Prevention and Control Section A - (To be completed by student and returned via email) Student Name Student Signature I am requesting the following reasonable accommodation(s): It is necessary for me to have this accomodation for the following reason(s): q Required: Attach documentation to support request. Documentation should indicate an assessment was conducted or diagnosis rendered to support request for reasonable accommodation. The student should retain a copy of this form. The original is filed by the New York State Office of Fire Prevention and Control. ANDREW M. CUOMO Governor JOHN P. MELVILLE Commissioner BRYANT D. STEVENS State Fire Administrator Sponsoring Agency County Phone # Email Address Preferred Method of Communication q Telephone q Email Course Name and Number Date Application for reasonable accommodations for state fire training may be made using this form and submitted via email to the Division’s Designee for Reasonable Accommodation (DRA), Deputy State Fire Administrator William R. Davis, Jr. at [EMAIL REDACTED] or by mail to: 1220 Washington Avenue, Bldg. 7A, Floor 2 • Albany, NY 12226. If the request is made to the instructor, the instructor will forward the request to the DRA. All confidential information received by OFPC pertaining to your request shall be handled as such. All medical information is confidential and maintained separately from your training records.