Title VI Form

First Name

Last Name

Street Address

Street Address Line 2

City

Zip Code

Primary Phone

Email

If Applicable, name of persons who allegedly discriminated against you

Non-Discrimination:

Sex

Age

Disability

Title VI:

Race

Color

National Origin

Date of Alleged Incident:

Location and position of person(s) who alleged discrimination against you if known:

Explain Briefly and clearly as possible what happened and how you believe you were discriminated against. Indicate who was involved. Be sure to include how you feel other persons were treated differently than you. Please attach any additional material about your complaint.

Why do you believe these events occurred?

What other information do you think is relevant to this complaint?

How can this issue be resolved to your satisfaction?

Please list the names, addresses, phone numbers and job titles of the person(s) we may contact for additional information about your complaint (witnesses, fellow employees, supervisors, others):

Additional information

Factuality Agreement

In submitting this form, you agree you understand the policy and procedures for the ADA/Nondiscrimination/Title VI will be followed. Additionally, you attest that the information you provided is true and correct as you know it.

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