ADA / Title VI / Non-Discrimination Complaint Form

Complaintant Information

* Full Name:

* Home Address:

* City:

* State:

* Zip Code:

* Email Address:

* Best Daytime Phone Number:

Additional Phone Number:

Complaint Information

* Date of alleged discriminatory incident:

* City department where alleged incident occurred:

* Name(s) of City employee(s) involved, if known:

* Please explain as clearly as possible what happened and how you experienced discrimination or were denied access or accommodation. Indicate who was involved and include the names and contact information of any witnesses. If the incident took place on a StarMetro bus, please provide identifying information (bus number, route, direction you were traveling, etc.) if you are able to do so:

* Have you filed this complaint with any other federal, state, or local agency or with any federal or state court?

Yes

Please provide information about the agency/court where the complaint was filed:

* Agency/courtname:

* Agency/court contact's name:

* Agency/court contact's address:

* City:

* State:

* Zip Code:

* Phone Number:

You may attach written materials, photographs, or other documentation that you believe is relevant to your complaint.

Optional Upload #1:

Optional Upload #2:

* Complaintant Signature

By clicking "Submit", you are confirming that you have read and agree with the terms and conditions of the Talgov.com Privacy Policy.