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Non-Discrimination and Title VI Complaint Form
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Non-Discrimination, ADA and Title VI Complaint Form
This is where you can file a Non-Discrimination, ADA or Title VI Complaint.
Name (Complainant)
*
Please enter your name
First
Last
Phone #
*
Please enter a good contact number for you.
Home Address
*
Please enter your home address, city state and zip.
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
If Applicable, name of persons who allegedly discriminated against you
Please list the name of person(s) who allegedly discriminated against you.
Basis of Non-Discrimination and/or Title VI Action(s) (Check all that might apply)
Non-Discrimination:
Basis of Non-Discrimination Action(s) (Check all that might apply)
Sex
Age
Disability
Title VI:
Basis of Title VI Action(s) (Check all that might apply)
Race
Color
National Origin
Date of Alleged Incident:
*
MM slash DD slash YYYY
Location and position of person(s) who alleged discrimination against you if known:
Please list the 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 whas involved. Be sure to include how you feel other persons were treated differently than you. Please attach any additional material about your complaint.
*
Explain Briefly and clearly as possible what happened.
Additional information
Please upload any additional information relevant to your complaint.
Max. file size: 50 MB.
Why do you believe these events occurred?
*
Please explain why do you believe these events occurred?
What other information do you think is relevant to this complaint?
*
Please list any other relevant information.
How can this issue be resolved to your satisfaction?
*
Please list how this issue can 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):
Please list additional people we can contact about your complaint.
Your Email Address
Please enter your emails address
CAPTCHA
I Agree
*
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.
Name
This field is for validation purposes and should be left unchanged.
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