NCR Special needs request form
NCRC General Meeting for September 15, 2007

( please print and check as many as apply)

If you require assistance to make the meeting and/or the meeting facilities accessible, it is essential that you complete and return this form before September 7, 2007 to:

Office of the REVP - NCR, Public Service Alliance of Canada, 
15 Holland Avenue Ottawa ON  K1Y 4T2
Telephone: (613) 560-4381, TDD: (613) 594-9394, fax: (613) 761-7606

General Information:

Name: __________________________________________________________

Tel.: __(______)___________________   TDD:__________________________

Fax:  __________________________       Email:_________________________

Meeting Status: Delegate ______   Observer ______   Guest ______

Please describe your needs and how we may accommodate you: 
(Ex.: I cannot walk long distances, food allergies/special diet, guide dog, etc.)

Personal Care:
I require a personal care attendant to assist me in meeting personal needs during the meeting    �Yes   �No

Will your personal attendant accompany you to this meeting    �Yes   �No

Do you require assistance in this regard from the meeting organizers?    �Yes   �No

Please specify if yes:___________________________________________________

Communications: 
�American Sign Language   �Oral Interpretation   �Sound Amplification 

�Assistance for emergency evacuation of meeting area?   

Alternate Media:    �Braille   � Large Print  �3½ Diskette (rtf, text format)