Complaint Of Discrimination printable pdf download

Complaint Of Discrimination

State of Florida Department of Transportation

275-010-10

Title VI / Nondiscrimination Program

EQUAL OPPORTUNITY OFFICE

Complaint of Discrimination

03-07

Complainant(s) Name:

Complainant(s) Address:

Complainant(s) Phone Number:

Complainant's Representative's Name, Address, Phone Number and Relationship (e.g. friend, attorney, parent, etc):

Name and Address of Agency, Institution, or Department Whom You Allege Discriminated Against You:

Names of the Individual(s) Whom You Allege Discriminated Against You (If Known):

Date of Alleged Discrimination:

Race

Color

National Origin

Discrimination

Sex

Age

Handicap/Disability

Because Of:

Income Status

Retaliation

Other

Please list the name(s) and phone number(s) of any person, if known, that the Florida Department of Transportation could contact for

additional information to support or clarify your allegation(s).

Please explain as clearly as possible how, why, when and where you believe you were discriminated against. Include as much

background information as possible about the alleged acts of discrimination. Additional pages may be attached if needed.

Complainant(s) or Complainant(s) Representatives Signature:

Date of Signature:

Complaint Of Discrimination