nm3clol-public/Cumberland_Plateau_Planning_District_Commission/DISCRIMINATION-COMPLAINT-FORM

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document	DISCRIMINATION-COMPLAINT-FORM	../DISCRIMINATION-COMPLAINT-FORM.pdf	Cumberland_Plateau_Planning_District_Commission	null	application/pdf	13915	52eabf97e6bf514c242ceb5474cf3ae8ad92c644abf3f976049e9538613407bb	1db2c506c3d9a9bc61a427f4141f918eae73eafb

DISCRIMINATION COMPLAINT FORM

Please provide the following information in order to process your complaint. Assistance is

available upon request. Complete this form and mail or deliver to:

Cumberland Plateau Planning District Commission, Title VI Coordinator, P.O. Box 548, 224

Clydesway Road, Lebanon, VA 24266

You can reach our office Monday-Friday from 8:00 am to 5:00 pm at (276) 889-1778, or you

can email the Cumberland Plateau Planning District Commission Title VI Coordinator at

judyharris@bvu.net.

Complainant's Name: _____________________________________________________________

Street Address: __________________________________________________________________

City: ____________________________ State: _______________________ Zip Code: _________

Telephone No. (Home): _________________________ Business: __________________________

Email Address: ________________________________

Person discriminated against (if other than complainant):

Name: _________________________________________________________________________

Street Address:

City: ____________________________ State: _______________________ Zip Code: ________

Telephone No.: __________________________

The name and address of the agency, institution, or department you believe discriminated against

you.

Name: ________________________________________________________________________

Street Address:

City: ____________________________ State: _______________________ Zip Code:

Date of incident resulting in discrimination: __________________

Describe how you were discriminated against. What happened and who was responsible? If

additional space is required, please either use the back of form or attach extra sheets to form.

DISCRIMINATION COMPLAINT FORM

Please provide the following information in order to process your complaint. Assistance is available upon request. Complete this form and mail or deliver to:

Cumberland Plateau Planning District Commission, Title VI Coordinator, P.O. Box 548, 224 Clydesway Road, Lebanon, VA 24266

You can reach our office Monday-Friday from 8:00 am to 5:00 pm at (276) 889-1778, or you can email the Cumberland Plateau Planning District Commission Title VI Coordinator at

judyharris@bvu.

Complainant's Name:

Street Address:

City: State: Zip Code:

Telephone No. (Home): Business:

Email Address: Person discriminated against (if other than complainant):

Name:

Street Address:

City: State: Zip Code:

Telephone No.:

The name and address of the agency, institution, or department you believe discriminated against

you.

Name:

Street Address: City: State: Zip Code:

Date of incident resulting in discrimination:

Describe how you were discriminated against. What happened and who was responsible? If additional space is required, please either use the back of form or attach extra sheets to form,

Does this complaint involve a specific individual(s) associated with the Cumberland Plateau

Planning District Commission? If yes, please provide the name(s) of the individual(s), if known.

Where did the incident take place?

Are there any witnesses? If so, please provide their contact information: Name:

Street Address:

City: __________________________ State: _______________________ Zip Code:

Telephone No.: ________________________

Name: _____________________________________________________________

Street Address:

City: __________________________ State: ______________________ Zip Code: _________

Telephone No.: ________________________

Did you file this complaint with another federal, state or local agency; or with a federal or state court? o YES o NO

If answer is Yes, check each agency complaint was filed with: o Federal Agency o State Court o Federal Court o Local Agency o State Agency o Other

Please provide contact person information for the agency you also filed the complaint with:

Name: ______________________________________________________________

Street Address:

City: State: Zip

Code:

Telephone No.:

Sign the complaint in the space below. Attach any documents you believe support your complaint.

---

Complainant's Signature Signature Date

Does this complaint involve a specific individual(s) associated with the Cumberland Plateau Planning District Commission? If yes, please provide the name(s) of the individual(s), if known. Where did the incident take place?

Are there any witnesses? If so, please provide their contact information: Name:

Street Address:

City: State: Zip Code:

Telephone No.:

Name:

City: State: Zip Code:

Telephone No.

Did you file this complaint with another federal, state or local agency; or with a federal or state court? 0 YES o NO

If answer is Yes, check each agency complaint was filed with: © Federal Agency State Court Federal Court Local Agency State Agency 0 Other Please provide contact person information for the agency you also filed the complaint with:

eoo°

Name:

Street Address:

City: State Zip Code:

Telephone No.:

Sign the complaint in the space below. Attach any documents you believe support your complaint.

‘Complainant's Signature Signature Date