Affirmative Action - Nys Department Of Motor Vehicles printable pdf download

Affirmative Action - Nys Department Of Motor Vehicles

Lisa G. DiCocco

Affirmative Action Officer

Designee for Reasonable

Accommodation (DRA)

ADA Coordinator

AFFIRMATIVE ACTION

6 E MP I RE S TA TE P LA ZA

A LB A NY, NY 12228

Title VI Complaint Form

Title VI of the Civil Rights Act and related Nondiscrimination authorities requires that, “No person

in the United States shall, on the basis of race, color, national origin, sex, age, disability, low income,

and limited English proficiency (LEP), be excluded from participation in, be denied the benefits of, or

be otherwise subjected to discrimination under any licensing program or activity receiving federal

financial assistance.” If you feel you have been discriminated against in licensing services

provided by the New York State Department of Motor Vehicles, please provide the following

information to assist in processing your complaint.

PLEASE PRINT CLEARLY:

Name:

Home Address:

City:

State:

Zip Code:

Daytime Phone: (_____) _____________________________ Mobile Phone: _ (_____) ________________________

Email address:

Individual experiencing discrimination:

Home Address: __________________________________________________________________________________________________

City: ______________________________________________ State: __________ Zip Code: ____________________

Daytime Phone: _ (_____) _____________________________ Mobile Phone: _ (_____) ________________________

Email address: __________________________________________________________________________________________________

Affirmative Action - Nys Department Of Motor Vehicles