Title VI Complaint Form

First Name *

Last Name *

Address1 *

Address2

City *

State *

Zip *

Email *

Phone *

Please indicate on what grounds you believe you have been discriminated against. *

Race / Color
National Origin
Disability

(check all that apply)

Date of Alleged Incident *

Explain as briefly and clearly as possible what happened and how you believe you were discriminated against. Indicate who was involved. Be sure to include how you feel other persons were treated differently than you. *

Why do you believe these events occurred? *

What other information do you think is relevant to the investigation?

How can this/these issue(s) be resolved to your satisfaction?

Please list below any person(s) we may contact for additional information to support or clarify your complaint. (witness, fellow employees, supervisors, others):

Attorney Name

Attorney Email *

Attorney Address / Phone

Website