Civil Rights Complaint Form (Page 2 of 2) in pdf

Please print and sign your name acknowledging that you have obtained permission to file

this complaint on behalf of the third party

Printed

Name__________________________________Signature______________________

Section III

I believe the discrimination I experienced was based on (circle all that apply)

Race__________ Color __________ National Origin__________ Disability__________

Date of alleged discrimination (Month, Day, Year):____________________________

Explain what happened and why you believe that you were discriminated against. Describe

all persons 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 more space is needed, please use the back of this form.

Section IV

Have you previously filed a Civil Rights complaint with this agency?

Circle the appropriate answer -

Yes

Section V

Have you filed this complaint with any other Federal, State or local agency or with any

Federal or State court? Circle the appropriate answer - Yes

If yes, check all that apply:

[ ] Federal Agency:______________________

[ ] State Agency:____________________

[ ] Federal Court:________________________

[ ] Local Agency:____________________

[ ] State Court:___________________________

Please provide contact information at the agency/court where the complaint was filed:

Name________________Title______________________Phone Number______________

Agency___________________________Address_________________________________

Section VI

Name of agency complaint is against:___________________________________________

Contact person:_________________________________________Title:_______________

Telephone Number:_________________________________________________________

You may attach any written materials or other information that you think is relevant to

your complaint. Signature and date required

_________________________ _______________________________ ___________

Print your name

Sign your name

Date

Please submit this form in person to:

Mail this form to:

Amarillo City Transit

City of Amarillo

801 South East 23

P.O. Box 1971

Amarillo, Texas 79102

Amarillo, Texas 79105

Route 4 stops at the front door

Date Received:______________________________

Received By:________________________________

Civil Rights Complaint Form Page 2

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