DISCRIMINATION COMPLAINT FORM
Type of Complaint?
Title VI Complaint
Title VI Related? I believe the discrimination I experienced was based on my:
VT Public Accommodation Related? I believe the discrimination I experienced was based on my:
Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons who were involved. Include name and contact information of the person(s) who discriminated against you (if known) as well as names and contact information of any witnesses.
Street Address Line 2
State / Province
Postal / Zip Code
Please enter a valid phone number.
Should be Empty:
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