(Act) Civil Rights Complaint Form (Ada) - Amarillo City Transit printable pdf download

(Act) Civil Rights Complaint Form (Ada) - Amarillo City Transit

Civil Rights Complaint Form

English

(ACT) Civil Rights Complaint Form (ADA)

If information is needed in another language, contact 806-378-6842.

Atención Sesión Pública Convocatoria Aviso 806-378-6842 Para Obtener

Información –

Nếu thông tin là cần thiết trong một ngôn ngữ khác, liên hệ 806-378-6842 –

ACT is committed to ensuring that no person is excluded from participation in or denied

the benefits of its services on the basis of disability, race, color or national origin, as

provided by Title VI of the Civil Rights Act of 1964, as amended, and the Americans with

Disabilities Act (ADA), as amended,. Title VI complaints must be filed within 180

business days and ADA complaints 90 business day from the date of the alleged

discrimination.

The following information is necessary to assist us in processing your complaint. If you

require any assistance in completing this form, please contact the General Manager by

calling at 806-378-6842. The completed form must be returned to:

Amarillo City Transit,

Attention: Transit Director

P.O. Box 1971

Amarillo, Texas 79105

Section I

Your Name:

Home Phone:

Street Address:

Work Phone:

E-Mail Address:

City, State. & Zip Code:

Do you need this information in an accessible format?

Large Print

TDD

Audio Tape

Other_________________________________

Section II

Are you filing this complaint on your own behalf: Yes*

*If you answered yes, go to Section III

If no, please supply the name and relationship of the person for whom you are complaining:

Name__________________________________________Relationship____________

Please explain why you have filed a complaint for a third party:_______________________

________________________________________________________________________

(Act) Civil Rights Complaint Form (Ada) - Amarillo City Transit