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2. Name
3. Email Address
5. Address
7. City
8. State
9. Zip Code
11. Phone Number
12. Fax Number
14. Accessible Format Requirements?*

    Please choose from the options below.

    1. Large Print
    2. TDD
    3. Audio Tape
    4. Other
15. Are you filling this complaint on your own behalf? *
    -- Select One --Yes No

    Please choose one option
17. Please name the person and the relationship of the person.
    Please provide person name and relation
18. Please explain why you have filed this form for a third part?
    Please detail your reason.
20. Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party.
    -- Select One --Yes No

    Only select one option.
21. I believe the discrimination I experienced was based on:

    1. Race
    2. Color
    3. National Origin

    Please select one or all options.
23. Please explain what happened and why you believe you were discriminated against. Describe all person who were involved. Include the name and contact information of the person(s) who discriminated against you (if known) as well as names and contact information of any witnesses (if known).
    Please be as detailed as possible.
25. Have you previously filed an ADA complaint with this agency?*
    -- Select One --Yes No

    Please select one option only.
26. Date of previous complaint
    Date of previous complaint
    Please select a date
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28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit Submit and Print

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