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EXHIBIT 3 <br /> <br />Title VI Complaint Form <br />Title VI of the 1964 Civil Rights Act requires that “No person in the United States shall, <br />on the ground of race, color, or national origin, be excluded from participation in, be <br />denied the benefits of, or be subjected to discrimination under any program or activity <br />receiving federal financial assistance.” If you feel you have been discriminated against <br />in transit services, please provide the following information in order to assist us in <br />processing your complaint and send it to: <br />Title VI Coordinator <br />Orange Public Transportation <br />PO Box 8181 <br />600 Highway 86 N <br />Hillsborough, NC 27278 <br />Please print clearly: <br />Section I: <br />Name: <br />Address: <br />Telephone (Home):Telephone (Work): <br />Electronic Mail Address: <br />Accessible Format <br />Requirements? <br />Large Print Audio Tape <br />TDD Other <br />Section II: <br />Are you filing this complaint on your own behalf? Yes*No <br />*If you answered "yes" to this question, go to Section III. <br />If not, please supply the name and relationship of the person for whom you <br />are complaining: <br />Please explain why you have filed for a third party: <br />Please confirm that you have obtained the permission of the aggrieved <br />party if you are filing on behalf of a third party. <br />YesNo <br />Section III: <br />I believe the discrimination I experienced was based on (check all that apply): <br />[ ] Race [ ] Color [ ] National Origin <br />Date of Alleged Discrimination (Month, Day, Year): __________ <br />Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all <br />persons who were involved. Include the name and contact information of the person(s) who discriminated against you <br />(if known) as well as names and contact information of any witnesses. If more space is needed, please use the back <br />54 <br />ReturntoAgenda