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2. Contact Name *

   First and Last Name

3. Name of Individual Trained in ADA*

   First and Last Name

5. Business Name*
6. Business Address*

   Street Address, City

8. Email Address*
9. Phone Number
11. Types of Jobs Hiring For (if applicable)
13. Training Completed

    Please check all that apply.

    1. Understanding and Applying the Americans with Disabilities Act Amendments Act and Its Regulations
    2. Effective Interactive Accommodation Process
    3. Disability Awareness to Increase Your Comfort, Confidence, and Competence
    4. Assistive Technology in the Workplace
    5. Ergonomics in the Workplace
    6. Other: _______________
14. If you selected "Other" for Training Completed, please list here.
16. I am interested in additional training in the following area(s):*

    Please check all that apply.

    1. Best Practices in Hiring Individuals with Disabilities
    2. Best Practices in Creating Inclusive Work Environments
    3. Strategies for Managing Individuals with Disabilities at Work
    4. Federal and State Incentives for employing Individuals with Disabilities
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18. 1. Receive an email copy of this form.
19. Email address

    This field is not part of the form submission.

20. Submit

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