Complaint Form

1

Name* This field is required.

First Name

Last Name

2

Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

3

Phone Number* This field is required.

Please enter a valid phone number.

4

Email

example@example.com

5

Accessible Format Requirements?

Large Print

TDD

Audio Tape

Other

6

Are you filing this complaint on your own behalf?* This field is required.

Yes

No

7

Can you provide a name and contact information of the individual for whom you are submitting the complaint for?

8

Where did the incident occur?* This field is required.

Vermont

New Hampshire

9

What type of complaint would you like to file?

Title VI (Discrimination based on Race, Color, or National Origin)

VT Public Accommodation (Discrimination based on Race, Color, National Origin, Marital Status, Creed, Gender, Sex, or Sexual Orientation)

ADA (Discrimination based on a disability)

General Feedback (General feedback or complaint about our service)

10

What type of complaint would you like to file?

Title VI (Discrimination based on Race, Color, or National Origin)

ADA (Discrimination based on disability)

General Feedback (General Feedback or complaint about our service)

11

I believe the discrimination I experienced was based on my:Check all that apply

Creed

Marital Status

Sex

Gender Identity

Sexual Orientation

12

Welcome

Please fill out this form if you believe you have been discriminated against by Advance Transit (AT). AT operates its services and programs without regard to race, color, or national origin as protected by the law under Title VI of the Civil Rights Act of 1964. If you feel you have been discriminated against, please complete this form and submit it electronically to AT.

13

Title VI Procedures* This field is required.

14

I believe the discrimination that I experienced was based on

Race

Color

National Origin

15

Have you previously filed a Title VI complaint with this agency?

Yes

No

16

Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court?

Yes

No

17

Date of alleged incident

Date

18

Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons who were involved. Include the name and contact information of the person(s) who discriminated against you (if known) as well as names and contact information of any witnesses. * This field is required.

19

You may attach any written materials or other information that you think is relevant to your complaint.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

20

A signature and date is required to submit this form* This field is required.