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Date <br /> Voluntary Title VI Public Involvement <br /> Title VI of the Civil Right's Act of 1964 requires North Carolina Department of <br /> Transportation to gather statistical data on participants and beneficiaries of the agency's <br /> federal-aid highway programs and activities. The North Carolina Department of <br /> Transportation collects information on race, color, national origin and gender of the <br /> attendees to this public meeting to ensure the inclusion of all segments of the population <br /> affected by a proposed project. <br /> The North Carolina Department of Transportation wishes to clarify that this information <br /> gathering process is completely voluntary and that you are not required to disclose the <br /> statistical data requested in order to participate in this meeting. This form is a public <br /> document. <br /> The completed forms will be held on file at the North Carolina Department of <br /> Transportation. For Further information regarding this process please contact Sharon <br /> Lipscomb,the Title VI Manager at telephone number 919.508.1808 or email at <br /> sipscomb @ncdot.gov. <br /> Project Name: Date: <br /> Meeting Location: <br /> Name(please print) Gender: <br /> ❑ Male ❑ Female <br /> General ethnic identification categories (check one) <br /> ❑ Caucasian ❑ Hispanic American ❑ American Indian/Alaskan Native <br /> ❑ African American I ❑ Asian/Pacific Islander Other: <br /> Color: National Origin: <br /> After you complete this form,please fold it and place it inside the designated box on the <br /> registration table. <br /> Thank you for your cooperation. <br />