Cambria County Transit Authority Ada Complaint Form Template (Page 2 of 2) in pdf

Provide the name of the person(s) who discriminated against you. If unknown, please provide

descriptive information to help identify the employee.

______________________________________________________________________________

Please explain as clearly as possible what happened and why you believe you were

discriminated against. If more space is needed, please use a separate sheet of paper.

______________________________________________________________________________

Please list the names and contact information for any and all witnesses.

______________________________________________________________________________

Section IV:

Have you previously filed an ADA complaint with CamTran? [ ] Yes

[ ] No

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

court? [ ] Yes

[ ] No

If yes, check all that apply:

[ ] Federal agency

[ ] Federal court

[ ] State agency

[ ] State court

[ ] Local agency

Please provide information about a contact person at the agency/court where the complaint

was filed.

Name and Title: __________________________________________________________

Agency: _________________________________________________________________

Address: ________________________________________________________________

City, State and Zip Code: ___________________________________________________

Telephone Number: _______________________________________________________

Section V:

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

complaint.

I affirm that I have read the above and that the information is true to the best of my knowledge

and belief. Signature and date required.

________________________________________________

_____________________

Signature

Date

Cambria County Transit Authority Ada Complaint Form Template Page 2