ADA Complaint Form

ADA Complaint Form

Americans with Disabilities Act
Client Name

First NameLast Name
Client Phone Number
Please enter a valid phone number.
Client Email
example@example.com
Client Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Incident:

MonthDayYear
Date
Time of Incident (best estimate)

Hour Minutes

AM/PM Option
Location of Incident
Describe Bus (number, destination or origin, driver, etc.)
Best guess is fine
Description of ADA Complaint
Please be as specific as possible
Date of report

MonthDayYear
Today's Date
Signature

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Please contact our office at 302-515-0001 with questions. You may submit this form online or in print. Please submit printed versions to:

CHEER, Inc.

546 S. Bedford St.

Georgetown, DE 19947

Attn: Human Resources
Should be Empty: