Candidate Request Form for Reasonable Accommodation 
INSTRUCTIONS TO CANDIDATE: If you have an accommodation based on a medical or religious need that limits you in applying for a position with Gusto, please complete the form below.
Email *
Name: *
Address: *
Phone: *

Position/Title of Role Applied for: 

 *

Recruiting Team Member (if known): 

 *

Do you have a medical condition that limits you in applying for a role at Gusto? 

 *

Part of the application process for which accommodation is requested: 

 *
Required

Accommodation being requested: 

 *

How will the accommodation assist you in this process: 

 *

If equipment is being requested, please specify if a specific brand or model is needed:

 *

Verification by Licensed Healthcare Provider

In cases where a medical condition is not evident, documentation may be required to support the accommodation. If additional documentation is needed, you will be contacted directly to provide this.

Note: Failure to provide additional information that may be necessary, could result in delaying your request for a reasonable accommodation.

Date *
MM
/
DD
/
YYYY
Candidate Signature (please print name) *
A copy of your responses will be emailed to the address you provided.
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