Agenda - 03-17-2015 - 7c - Laserfiche WebLink

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16 *: /:II :1kW a� Title VI Complaint Form Title VI of the 1964 Civil Rights Act requires that "No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance." If you feel you have been discriminated against in transit services, please provide the following information in order to assist us in processing your complaint and send it to: Title VI Coordinator Orange Public Transportation PO Box 8181 600 Highway 86 N Hillsborough, NC 27278 Please print clearly: Section I: Name: Address: Telephone (Home): Telephone (Work): Electronic Mail Address: Accessible Format Requirements? Lar e Print Audio Tape TDD Other Section II: Are you filing this complaint on your own behalf? Yes* No *If you answered "yes" to this question, go to Section III. If not, please supply the name and relationship of the person for whom you are complaining: Please explain why you have filed for a third party: Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party. Yes No Section III: I believe the discrimination I experienced was based on (check all that apply): [ ] Race [ ] Color [ ] National Origin Date of Alleged Discrimination (Month, Day, Year): Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons who were involved. Include the name and contact information of the person(s) who discriminated against you if known as well as names and contact information of any witnesses. If mores ace is needed, please use the back