224 lines
5.5 KiB
Markdown
224 lines
5.5 KiB
Markdown
---
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type: document
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title: DISCRIMINATION-COMPLAINT-FORM
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file: ../DISCRIMINATION-COMPLAINT-FORM.pdf
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tags:
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- Cumberland_Plateau_Planning_District_Commission
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docDate: null
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contentType: application/pdf
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contentLength: 13915
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sha256sum: 52eabf97e6bf514c242ceb5474cf3ae8ad92c644abf3f976049e9538613407bb
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sha1sum: 1db2c506c3d9a9bc61a427f4141f918eae73eafb
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---
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DISCRIMINATION COMPLAINT FORM
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Please provide the following information in order to process your complaint. Assistance is
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available upon request. Complete this form and mail or deliver to:
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Cumberland Plateau Planning District Commission, Title VI Coordinator, P.O. Box 548, 224
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Clydesway Road, Lebanon, VA 24266
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You can reach our office Monday-Friday from 8:00 am to 5:00 pm at (276) 889-1778, or you
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can email the Cumberland Plateau Planning District Commission Title VI Coordinator at
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judyharris@bvu.net.
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Complainant's Name: _____________________________________________________________
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Street Address: __________________________________________________________________
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City: ____________________________ State: _______________________ Zip Code: _________
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Telephone No. (Home): _________________________ Business: __________________________
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Email Address: ________________________________
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Person discriminated against (if other than complainant):
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Name: _________________________________________________________________________
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Street Address:
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City: ____________________________ State: _______________________ Zip Code: ________
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Telephone No.: __________________________
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The name and address of the agency, institution, or department you believe discriminated against
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you.
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Name: ________________________________________________________________________
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Street Address:
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City: ____________________________ State: _______________________ Zip Code:
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Date of incident resulting in discrimination: __________________
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Describe how you were discriminated against. What happened and who was responsible? If
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additional space is required, please either use the back of form or attach extra sheets to form.
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DISCRIMINATION COMPLAINT FORM
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Please provide the following information in order to process your complaint. Assistance is
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available upon request. Complete this form and mail or deliver to:
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Cumberland Plateau Planning District Commission, Title VI Coordinator, P.O. Box 548, 224
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Clydesway Road, Lebanon, VA 24266
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You can reach our office Monday-Friday from 8:00 am to 5:00 pm at (276) 889-1778, or you
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can email the Cumberland Plateau Planning District Commission Title VI Coordinator at
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judyharris@bvu.
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Complainant's Name:
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Street Address:
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City: State: Zip Code:
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Telephone No. (Home): Business:
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Email Address:
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Person discriminated against (if other than complainant):
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Name:
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Street Address:
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City: State: Zip Code:
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Telephone No.:
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The name and address of the agency, institution, or department you believe discriminated against
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you.
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Name:
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Street Address:
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City: State: Zip Code:
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Date of incident resulting in discrimination:
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Describe how you were discriminated against. What happened and who was responsible? If
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additional space is required, please either use the back of form or attach extra sheets to form,
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Does this complaint involve a specific individual(s) associated with the Cumberland Plateau
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Planning District Commission? If yes, please provide the name(s) of the individual(s), if known.
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Where did the incident take place?
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Are there any witnesses? If so, please provide their contact information:
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Name:
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Street Address:
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City: __________________________ State: _______________________ Zip Code:
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Telephone No.: ________________________
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Name: _____________________________________________________________
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Street Address:
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City: __________________________ State: ______________________ Zip Code: _________
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Telephone No.: ________________________
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Did you file this complaint with another federal, state or local agency; or with a federal or state court?
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o YES o NO
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If answer is Yes, check each agency complaint was filed with:
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o Federal Agency
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o State Court
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o Federal Court
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o Local Agency
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o State Agency
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o Other
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Please provide contact person information for the agency you also filed the complaint
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with:
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Name: ______________________________________________________________
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Street Address:
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City: State: Zip
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Code:
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Telephone No.:
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Sign the complaint in the space below. Attach any documents you believe support your complaint.
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_________________________ __________________________
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Complainant's Signature Signature Date
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Does this complaint involve a specific individual(s) associated with the Cumberland Plateau
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Planning District Commission? If yes, please provide the name(s) of the individual(s), if known.
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Where did the incident take place?
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Are there any witnesses? If so, please provide their contact information:
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Name:
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Street Address:
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City: State: Zip Code:
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Telephone No.:
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Name:
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City: State: Zip Code:
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Telephone No.
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Did you file this complaint with another federal, state or local agency; or with a federal or state court?
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0 YES o NO
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If answer is Yes, check each agency complaint was filed with:
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© Federal Agency
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State Court
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Federal Court
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Local Agency
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State Agency
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0 Other
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Please provide contact person information for the agency you also filed the complaint
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with:
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eoo°
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Name:
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Street Address:
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City: State Zip
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Code:
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Telephone No.:
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Sign the complaint in the space below. Attach any documents you believe support your complaint.
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‘Complainant's Signature Signature Date
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