Montezuma County Republican Central Committee
Disability Accommodation Request Form
Remote Participation Request
For County Precinct Caucus and County Assembly
(Compliance with Colorado HB24-1067)
Purpose
This form allows individuals with disabilities to request remote participation as a reasonable accommodation to participate in a County Precinct Caucus and/or County Assembly, as required under HB24-1067 and applicable state and federal accessibility laws. Completion of this form is voluntary and intended solely to facilitate accessibility and statutory compliance.
Requestor Information
Full Legal Name:
Residential Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
Email Address:
example@example.com
Party Affiliation (Required)
Political Partv Affiliation:
*
Date Party Affiliation Was Established (MM/DD/YYYY):
-
Month
-
Day
Year
Date
(Affiliation required to verify eligibility under Colorado election law.)
Event Selection
Event Type
County Precinct Caucus
County Assembly
County:
Precinct Number (if applicable):
Event Date(s):
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Remote Participation Accommodation Request
I am requesting remote participation as a disability-related accommodation for the event(s) selected above.
Please provide any information necessary to facilitate this request (optional):
Acknowledgment
I certify that the information provided above is accurate to the best of my knowledge. I understand that this information will be used solely to provide reasonable accommodations and verify eligibility, consistent with HB24-1067.
Signature:
Date:
-
Month
-
Day
Year
Date
Submission Instructions
This form is available on the Montezuma County Republican Central Committee website.
Forms must be submitted no later than days prior to the county caucus or county assembly, unless otherwise permitted by law or party rule.
Email: montezumagop@gmail.com
Website: https://www.montezumagop.com
Mail: Montezuma County Republican Central Committee, P.O. Box 113, Cortez, CO 81321
Party Organization Use Only
Date Received:
-
Month
-
Day
Year
Date
Remote Access Provided (method):
Handled By:
Statutory Authority: This accommodation request process is established pursuant to Colorado House Bill 24-1067 (HB24-1067).
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