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American with Disabilities Act (ADA) Grievance Form
Complainant:
*
Relationship to Individual Discriminated Against:
*
Address:
Street Address
City
State
Zip
Phone Number:
*
Email:
*
Individual Discriminated Against:
*
Address:
Street Address
City
State
Zip
Phone Number:
*
Email:
*
Alleged Violation: Date(s) and Place of Occurrence:
*
Description of Violation and City Department Involved:
*
Requested Action by City to Correct Violation:
*
Has Complaint been Filed with State or Federal Agency?
Yes
No
If Yes, Name of Agency:
Date Filed:
Contact Person:
Complainant Signature:
Complainant Signature:
First Name
Last Name
Email
Choose how to sign
Draw
Type
I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.
Date:
disregard this