Ada Complaint Form printable pdf download

Ada Complaint Form

ADA COMPLAINT FORM

Please print out this form, fill it out and mail it to: Northwestern CT Transit District, or

ConnDOT, or the Federal Transit Administration.

Name:

Street Address:

City or Town/State/Zip Code:

________________________________________________________________________

Phone:

Please provide the date(s) and location of the alleged discrimination, the name(s) of

the individual(s) who allegedly discriminated against you including their titles (if

known) or the lack of accessibility.

Please provide the names, addresses and telephone numbers of any witnesses.

Explain as briefly and as clearly as possible what happened, how you feel that you

were discriminated against and who was involved. Please include how other persons

were treated differently from you.

Signature/Date ___________________________

You may use additional sheets of paper if necessary. Also include any written materials

pertaining to your complaint.

Address:

NWCTD

957 East Main Street

Torrington, CT 06790

Ada Complaint Form