DISCRIMINATION COMPLAINT FORM
Type of Complaint?
ADA Complaint
Title VI Complaint
Unsure
Other
Title VI Related? I believe the discrimination I experienced was based on my:
Race
Color
National Origin
VT Public Accommodation Related? I believe the discrimination I experienced was based on my:
Race
Creed
National Origin
Color
Marital Status
Sex
Gender Identity
Sexual Orientation
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.
*
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date
*
-
Month
-
Day
Year
Date
Hour Minutes
Signature
*
Submit
Should be Empty: