Disability Accommodation Request

"*" indicates required fields

Name

This field is for validation purposes and should be left unchanged.

Disability Accommodation Request

If you have a disability and would like modifications to policies, practices, or procedures, auxiliary aids and services, or removal of architectural and communication barriers (collectively “accommodation(s)”) while using GW ADR’s services, you are welcome to use this form to share your request. You may also share your request in another written format or orally, whichever is easiest for you. Please submit your completed form to David A. Weintraub at David@GWSettled.com or Steven M. Greenbaum at StevenG@GWSettled.com. GW ADR will review the request and provide a response in a prompt manner.

Your information

Name*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

What services are you requesting from GW ADR? (For example, arbitration or mediation.)*

When and where do you need accommodation?*

What accommodation are you requesting?*

Untitled*

More information on this request is attached.

Date*

Type or Print Name*