Name_____________________________________________________________________________________________

Address _________________________________________________City____________________Zip________________

Phone:_________________________Home:_________________ Work:__________________Mobile:______________

Email:____________________________________________________________________________________________

Basis of Complaint (mark all that apply): Race Color Religion National Origin Sex/Gender Sexual Orientation Gender Identity Age Disability Retaliation Other, please specify:

Name:_____________________________________________________________________________________________

Name of Organization:________________________________________________________________________________

Address._________________________________________________City____________________Zip________________

Telephone____________________________________________________________How were you discriminated against? (Attach additional pages if more space is needed)

_____________________________________________________________________________________________________________________________________________

Title VI, ADA and EEO Complaint Form

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Were there any other witnesses to the discrimination? Name Organization, Title/Work Telephone, Home Telephone; Name Organization, Title/Work Telephone, Home Telephone: How would you like to see this situation resolved?

________________________________________________________________________________________________________________________________________________

Have you filed your complaint, grievance, or lawsuit with any other agency or court?

Who_________________________________________________________________________When______________________________________________________________

Status (pending, resolved, etc.)____________________________________________________Result, if known_____________________________________________________

Complaint number, if known________________________________________________________________________________________________________________________

Do you have an attorney in this matter?_____________________________________________ Name______________________________________________________________

Phone__________________________Address________________________________________City________________________________________Zip____________________

I affirm that I have read the above complaint and that it is true to the best of my knowledge, information and belief.

Complainant:

Name: _______________________________________________________________________________________

Signature:________________________________________________________Date_________________________