First Name:

Last Name:

Address:

City:

State: Select a State... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming

Zip Code:

Phone Number including Area Code: ()

This number is a TTY number

Fax Number including Area Code: ()

E-mail Address:

This is my personal E-Mail Address.

This is my work / business E-Mail Address.

Please select one of the following that most appropriately fits you.

I am a Select... person with a disability family or friend of a person with a disability service provider community member

Please select your primary disability if you are a person with a disability.

Select... Amputation Arthritis Blind Cerebral Palsy Chemical Dependency Deaf Degenerative Disease Diabetes Epilepsy Environmental Sensitivity Hard of Hearing Head / Injury HIV or AIDS Learning Disability Mental Retardation Multiple Sclerosis Muscular Dystrophy Other Orthopedic Impairment Polio Psychiatric Disability Speech Impairment Spina Bifida Spinal Cord Injury Stroke Visual Impairment Other Disability I do not wish to list my disability.

Please select one of the following that most appropriately fits you.

My ethnicity is: Select... African American Asian or Pacific Islander Caucasian Hispanic Native American or Alaskan Native I do not wish to report my ethnicity.

Please pick a general category so your question can be processed quickly.

Select... ADA issues Advocacy Services Architectural Accessibility Communications Accessibility Consumer or Legal Rights Counseling Services Daily Living or Self Care Education or Training Employment Equipment or Assistive Devices Finances or Benefits Health Care or Nutrition Housing Info about Disabilities Info about Independent Living Centers Mobility Personal Assistant Services Personal Growth or Self Help Social or Recreation State or Local Government Services for Children with Disabilities Transportation Statistics or Surveys Voter Education Project Other

Question(s):

I would prefer your staff to respond to my question(s) by:

Select... Mail E-Mail Phone Fax