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Business Referral for Accessibility
This form is to be filled out by the Accessibility Ambassador.
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* Indicates required question
Accessibility Ambassador Name (Your first & last name)
*
Your answer
Your Email Address
Your answer
Your Phone Number
Your answer
Business Name (the business you are referring)
*
Your answer
Referral's Name (person you are referring)
*
Your answer
Their Phone Number
*
Your answer
Their Email Address
*
Your answer
Business Website
Your answer
What date did you give your Accessibility Ambassador card to this person?
*
MM
/
DD
/
YYYY
How do you know this person / business?
Friend or family
I am their patient/client
First time interacting with this business
Other:
Clear selection
What accessibility problems do they need resolved? Why are you referring them?
*
Your answer
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