COMPLAINT FORM – Lakewood Shuttle

NAME*
First Last
DATE*
ADDRESS*
Street Address City State ZIP Code
TELEPHONE (HOME)*
TELEPHONE (CELL)
EMAIL
Accessible format required?
- Large Print
- Audio Tape
- TDD
- Other

Are you filling out this complaint form on your own behalf?*
- Yes
- No

If the answer to the above question is NO, please complete the following information on the person being discriminated against. If the answer to the above question was YES, please click 'next'.

NAME

ADDRESS
Street Address City State ZIP Code
TELEPHONE (HOME)
TELEPHONE (CELL)
EMAIL
Relationship with the person for whom you are complaining:
Please explain why you have filed for a third party:
Please confirm that you have received permission from the aggrieved party if you are filing on behalf of a third party.
- Yes
- No

Which of the following best describes the reason you believe the discrimination took place?
- Race
- Color
- National Origin
- Other
On what date(s) did the alleged discrimination take place?
Date: Date:
Please describe the allege discrimination. Explain what happened and whom you believe is responsible. 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 any additional space is needed, add a sheet of paper.
Have you filed this complaint with any other Federal, State or local agency, or with any Federal or State court? List all that apply:
Federal Agency: Federal Court: State Agency: State Court: Local Agency:

If you have checked above, please provide information about a contact person as the agency / court where the complaint was filed. If not, please click 'next'.
NAME
TITLE
ADDRESS
Street Address City State ZIP Code
TELEPHONE (HOME)
TELEPHONE (WORK)
EMAIL

Please confirm below. You may send any written materials or other information that you think is relevant to your complaint to info@lakewoodshuttle.com and title it - 'Complaint form attachment from - your name'.*
- I hereby confirm all of the above information included in this complaint form submission.
DATE*
I WILL BE SENDING ATTACHMENTS*
- YES
- NO

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