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INTEGRATED <br /> MOBILITY 1 <br /> DIVISION <br /> GRANT .i w <br /> VOLUNTARY TITLE VI PUBLIC INVOLVEMENT <br /> Title VI of the Civil Rights Act of 1964 requires the North Carolina Department of <br /> Transportation (NC DOT) to gather statistical data regarding participants and <br /> beneficiaries of the agency's federal-aid programs and activities. NC DOT collects <br /> information on race, color, national origin and gender of the attendees to this public <br /> meeting to ensure the inclusion of all segments of the population impacted by a proposed <br /> project. <br /> NCDOT wishes to clarify that this information gathering process is completely <br /> voluntary and that you are not required to disclose the statistical data requested to <br /> participate in this meeting. This form is a public document used to collect data, only. <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 the <br /> NCDOT Title VI Program at telephone number 919.508.1808 or email at <br /> titlevi 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 ❑ Asian/Pacific Islander Other: <br /> American <br /> Color: National Origin: <br /> After completing this form, please fold and place it inside the designated box on the <br /> registration table. <br /> Thank you for your cooperation. <br /> FY26 VOLUNTARY TITLE VI PUBLIC INVOLVEMENT <br /> Last Updated: 04/01/2024 <br />