NCWRC Discrimination Complaint Form

North Carolina Wildlife Resources Commission

Americans with Disabilities Act (ADA)

Title II Grievance Form

Please complete, sign and submit this form to file your complaint.

Name

Email

example@example.com

Phone Number

Address

If someone is filling out this form on your behalf, please indicate that information below:

Name

Email

example@example.com

Phone Number

Address

DATE the alleged violation(s) occurred

Date

LOCATION(s) where the alleged violation(s) occurred

DESCRIPTION OF ACTIONS YOU BELIEVE ARE PROHIBITED by Section 504 of the Rehabilitation Act or Title II of the American with Disabilities Act. Please list names and addresses of persons who were involved and who can be contacted to provide information relevant to this grievance in the box below.

If you have any documents or information you would like the NCWRC to consider when reviewing your complaint, please send those to: ada.coordinator@ncwildlife.org

Are you aware of any efforts made to resolve this grievance through other informal means?

YESNO

If yes, please specify those means, and provide the status.

Have you filed a grievance on this alleged violation with any federal office of civil rights, other agency, or in court?

YESNO

If so, please specify, and provide the status.

Have you previously filed a complaint on this alleged violation with any other N.C. state agency?

YESNO

If so, please specify, and provide the status.

Please indicate your preferred method of communication.

EmailMailPhone

Please provide your contact information for the method selected above.

PRINTED NAME

DATE

Date

SIGNATURE

If you have a disability that requires a non-written form of communication, upon request, the NCWRC shall make reasonable efforts to effectively communicate with you. For more information, please contact the NCWRC ADA Coordinator at ada.coordinator@ncwildlife.org, or Luis J. Suau at (919) 707-0353 or luis.suau@ncwildlife.org.