Department of the Interior Accessible Technology Center

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ATC LOCATION

	1849 C Street NW Mail Stop 1013 Washington, DC 20240 Phone: 202-208-5481 TTY:202-208-6248

Service Request Form

Complete this form to request a recommendation on appropriate assistive technology and services. Please ensure completion of all contact information for employee and supervisor. If you have any questions, call DOI-ATC at 202-208-5481.

Date of Request:

How can we be of service? (pick all that apply)

Needs Assessment	Information request
Specific AT request	Demo tour
Training request	508 Testing
CAP Request	Loan

1. Name of person or Office requesting service:

2. Address/Contact Information:

Employee
Name:
Office:
Bureau:
Other:
Street Address:
City:
State:	Zip:
Telephone:
Email:
TTY:
Fax #:
Supervisor Other
Name:
Office:
Bureau:
Other:
Street Address:
City:
State:	Zip:
Telephone:
Email:
TTY:
Fax #:

How do you prefer to be contacted?

Mail	Phone	Email
TTY	Fax	Other

3. Disability of Interest

Deaf/hard of hearing	Blind	Low Vision
Cognitive	Dexterity
Explain:

How did you find out about DOI's Assistive Technology Services Center?

Read about it

Word of Mouth

Supervisor

Other

U.S. Department of the Interior
National Business Center
Accessible Technology Center
christine_E_louton@nbc.gov
Last Updated on 10/05/05