Reasonable Modification

Request Form

 

Please complete this form to request a reasonable modification of STAR Transportation services.

 

Submit the completed form to:  STAR Transportation Coordinator

 

EMAIL at: star@steubencoa.org

or

MAIL to: 317 S. Wayne Street, Ste. 1-B, Angola, IN 46703

 

Name: _______________________________________  Todays Date: _____________

Email: __________________________________   Phone Number: ________________

Street Address:_________________________________________________________

City: ___________________________________   Zip Code:_____________________

 

Description of Your Request:

____________________________________________________________________

________________________________________________________________________________________________________________________________________

____________________________________________________________________

 

Are you able to use STAR Transportation services without this modification?  

Yes   No

 

Please Explain:_________________________________________________________