* Required Field

Curb Ramp Request Program 2.0

I Need Access

I am a person with a disability as outlined under the
Americans with Disabilities Act (ADA)

I am submitting a request on behalf of another person with a disability as outlined under the
Americans with Disabilities Act (ADA)

Options:

If other, please describe (e.g request on behalf of someone else):

Accessibility

This will provide me access to:

Hold Ctrl to select multiple items

If other, please describe (e.g. doctor's office):

Location

Where is the missing/damaged curb ramp?

Street*

Cross Street*

Address of Curb Ramp Request Location*

e.g. 1120 SW 5TH or 5TH AND MAIN

Curb Ramp Request

Please choose all that apply:

NW Corner:

SW Corner:

NE Corner:

SE Corner:

If other, please describe. Add any other specific information:

Contact Information

Name*

Home Address

City

State

Zipcode

Phone Number*

Email Address*

Would you like to be called?

Would you like to be called? Yes No

Attach Photo

(Maximum file size: 30MB)

The City of Portland, Oregon