Disability Preference Verification Form

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CITY OF CHANDLER
DISABILITY PREFERENCE VERIFICATION FORM
For purposes of the Disability Preference, an individual with a disability means a person who
has a physical or mental impairment which substantially limits one or more major life activities,
or has a record of such impairment, or is regarded as having such impairment.
The preference will be applied only upon receipt by the Human Resources Division of this
completed and signed Disability Preference Application form. The completed form is intended
solely for use in connection with A.R.S. § 38-492. The information is requested on a voluntary
basis, will be kept confidential, and will not be shared with the hiring department. The refusal to
provide the requested information will not result in any adverse treatment.
Requests for reasonable accommodation in the interview and testing process should be made
directly to the Human Resources Division.
Position applied for:____________________________________________________________
Name of Applicant: _____________________________
Phone Number: ________________
To be completed by Applicant's Healthcare Provider:
CERTIFICATION OF DISABILITY
I hereby certify that:
1.
The above-named applicant:
/__/ is a patient of my practice
/__/ was seen by me on ___________ (date).
2.
The applicant has a physical or mental impairment which substantially limits one or more
major life activities, has a record of such impairment, or is regarded as having such impairment
(as those terms are defined under the Americans with Disabilities Act).
Signature of Healthcare Provider: _________________________________________________
Name and Title of Healthcare Provider: ____________________________________________
Address: ____________________________________________________________________
Phone No: ___________________________________________________________________
I understand that this document will be reviewed and that I may be asked to provide additional
information before the Disability Preference may be applied.
Signature of Applicant:__________________________________ Date:_____/_____/________
Return this form directly to:
City of Chandler, Human Resources Division, P.O. Box 4008, MS 703, Chandler, AZ 85244-4008 or fax under coversheet marked
"CONFIDENTIAL" to 480-782-2366.

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