Request For Disability Preference - Arizona
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1ARIZONA STATE HUMAN RESOURCES DIVISION
100 N. 15th Avenue, #261
Phoenix, AZ 85007
Request for Disability Preference
In accordance with A.R.S. 38‐492, an INDIVIDUAL WITH A DISABILITY who indicates interest in
employment with Agencies served by the State Human Resources Division shall be given preference.
For the purpose of this preference, INDIVIDUAL WITH A DISABILITY means anyone who has a
physical or mental impairment, which substantially limits one or more of his/her major life functions, or
has a record of such impairment or is regarded as having such impairment.
Preference will be awarded ONLY upon receipt of this signed and dated “Request for Disability
Preference” form. The completed form is intended for use solely in connection with A.R.S. 38‐492.
The information is requested on a voluntary basis and will be kept confidential. Refusal to provide the
requested information will not result in any adverse treatment.
Requests for reasonable accommodation in the interview/testing process should be made directly to the
hiring agency when they contact you.
Once you have completed this form, click the submit button to attach it to an email to be sent to the
HRIS Help Desk. You may also print the form and fax it to 602.542.4745.
…………………………………………………………………………………………………………………………………………………………....
I hereby request preference. I affirm/certify that I meet the above definition of an INDIVIDUAL
WITH A DISABILITY, and am eligible for preference.
Name: ___________________________________________________________________________
Last Name
First Name
M.I.
Address: ___________________________________________________________________________
___________________________________________________________________________
City
State
Zip Code
Phone: ___________________________________________________________________________
Home
Work
______________________________________________________
________________________
Signature (If submitting electronically, type your name in the box to
Date
certify that you are eligible to request preference)
Submit by Email
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