Form Pe-703 - Americans With Disabilities Act Complaint Form

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LISA G. DiCOCCO
Affirmative Action Officer
Designee for Reasonable
Accommodation (DRA)
ADA Coordinator
AF FI RM AT I VE A CT IO N
6
E M P I R E S T A T E P L A Z A • A L B A N Y, N Y
1 2 2 2 8
AMERICANS WITH DISABILITIES ACT COMPLAINT FORM
Please use this form to file a complaint based on disability in the provision of services, activities, programs, or benefits.
Please submit this form to the ADA Coordinator, Lisa G. DiCocco at the NYS Department of Motor Vehicles; you may
PE-701
find contact information for Lisa G. DiCocco on form
at
COMPLAINANT INFORMATION
Name:
Home Phone:
Home Address:
Email:
1. Your claim is made against:
State Agency:
Name:
Title:
Phone:
Address:
2. Location(s) and date(s) of the circumstances giving rise to your complaint:
Are the circumstances of your complaint continuing?
Yes
No
PE-703 (1/17)
PAGE 1 OF 2

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