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2. First Name
3. Last Name
5. Email
6. Are you willing to be contacted for more information?

   1. Yes
   2. No
8. Phone Number
10. Please Provide ADA Feedback Below:
    The City of Burlington is working on a ADA Transition Plan and the City would like your comments and concerns regarding facility accessibility to assist in the development of the Transition Plan. Please help with this process and list your concerns regarding accessibility of the public facilities within the City of Burlington.
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12. 1. Receive an email copy of this form.
13. Email address

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