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FORT BEND COUNTY PUBLIC TRANSPORTATION

ADA DISCRIMINATION COMPLAINT FORM

1.

Name (Complainant)

 

4. Person discriminated against (if other than complainant)

 

 

 

 

Name

 

 

2.

Home Address (Street, City, State, Zip Code)

Address

 

 

3.

Telephone (s)

 

City, State, Zip Code

 

 

 

 

 

 

 

E-mail Address

 

Telephone number(s)

 

 

 

 

 

 

 

5. Name of person(s) who allegedly

6. Date of allegedly incident

 

7. Location of alleged incident

 

discriminated against you, if known

 

 

 

 

 

 

 

 

 

 

 

8. Type of alleged discrimination

9. Explain what happened and

how you believe you were

 

 

 

discriminated against (how you feel another person were treated

 

 

 

differently than you) Indicate who was involved and explain their

 

 

 

role.

 

 

 

 

 

 

 

 

 

 

 

10.

Fully identify any person(s) we may contact for additional information to support of clarifying your

allegations [name, address, telephone(s)]

 

 

 

 

11.

What other information do you have which is relevant to an investigation of this complaint?

 

 

 

12.

How can your issue(s) be resolved to your satisfaction?

13. If you have filed this complaint with

 

 

FBCPT before, please specify when,

 

 

where, and how?

 

 

Signature

Date:

If you need more space, attach additional sheet(s). Attach any supporting documentation you have.

If you need more space, attach additional sheet(s). Attach any supporting documentation you have.

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