MCT Title VI

Muskogee County Public Transit Authority

Title VI Complaint Form
Contact Name
First*
Last*
Address*
Address Line 2
City*
State / Province / Region*
Postal / Zip Code*
Country*
Phone Number*
Email (Optional)
Date of the Incident*

MonthDayYear
Date
Describe how your rights were violated. What happened and who was responsible?*
What Muskogee Transit employee(s) was involved in the incident? i.e. Driver, Vehicle Number*
Where did the incident take place? Please provide location, vehicle number, driver's name, time*
Names and phone numbers of any persons, if known, that Muskogee Transit may contact for additional information to support or clarify your allegations
Did you file this complaint with another federal, state or local agency?
Attach any document you believe support your complaint

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By typing your name and date, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement.
Name
First*
Last*
Date*

MonthDayYear
Date
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Muskogee County Public Transit Authority