Accommodation Request Form
Your Legal Name
First Name
Last Name
Your Work Location
Please Select
Eskimo Joe's Clothes
Mexico Joe's
Eskimo Joe's
Eskimo Joe's Promotional Products Group
Stan Clark Companies
Your Job Title
Your Manager's Name:
Your Phone #
Format: (000) 000-0000.
Your Email
example@example.com
Identify your disability or limitation
How does your disability or condition affect your work
What specific accommodations are you requesting if known
Is the accommodation temporary or permanent?
Temporary
Permanent
How will the requested accommodation help you perform your job duties?
Please provide any additional information that may be useful in processing your accommodation request.
Please attach your medical documentation listing specific job duty restrictions.
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I.E. No lifting over 15 lbs, Limited use of Right Hand, etc.
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