Tillamook County Circuit Court Request for Accommodation by Person with Disability Applicant (name): Person submitting request (name if different from applicant): Applicant Address: Contact Phone Number: 1. Name of proceeding(s) to be covered: 2. Date(s) of proceeding(s): 3. Case Number (if applicable): 4. Applicant is: G Party G Witness G Juror G Attorney G Other (specify) ___________ 5. Type of disability needing accommodation: 6. Type of accommodation needed or preferred: Date: _____________________ ...................................................................... (Type or print name) ____________________________________ (Signature of applicant) As soon as possible, or at least four judicial days prior to the proceeding, submit this form to: Trial Court Administration, Tillamook County Circuit Court, 201 Laurel Ave, Tillamook, OR 97141 Phone: 503.842.2596 Fax: 503.842.2597 Revised 6/8/05 American LegalNet, Inc. www.USCourtForms.com