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U.S. DEPARTMENT OF HOMELAND SECURITY U.S. COAST GUARD CG-6080 (Rev. 03-06)

CONFIRMATION OF REQUEST FOR REASONABLE ACCOMMODATION
Date of Request

Employee/Applicant Data Name: Telephone: Organization:

Date of Receipt

ACCOMMODATION REQUESTED (Be as specific as possible, e.g., adaptive equipment, reader, interpreter.)

REASON FOR REQUEST

Return form to: (Enter Title/Address of Responsible Official)

SUBMITTED BY: TELEPHONE:
U.S. DEPT. OF HOMELAND SECURITY, USCG, CG-6080 (Rev. 03-06)

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