Apr 11, 2021
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ADA, Title VI Complaint Form
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ADA,Title VI Complaint form
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Please provide the following information necessary in order to process your complaint. Assistance is available upon request.
Upon completion this form will be emailed to info@tulsatransit.org, TULSA TRANSIT, Civil Rights Officer, P.O. Box 52488, Tulsa OK 74152
Complainant's Name:
*
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Telephone No. (Home):
*
Telephone No. (Work):
Person filling out form (if other than complainant)
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Date of the incident:
*
Form:
*
ADA Rights
Title VI Rights
Rights Violated
*
Race
Color
National Origin
Describe how your rights were violated. What happened and who was responsible?
*
What Tulsa Transit employee(s) was involved in the incident? i.e. Driver, Call Center, Security Officer
Where did the incident take place? Please provide location, bus number, driver's name, time, etc.
*
Did you file this complaint with another federal, state or local agency?
*
yes
no
If the answer is yes, check each agency complaint was filed with:
*
Federal Agency
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Other
Other
*
If you filed with another agency please provide the contact information for the Agency Representative:
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Louisiana
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Texas
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Washington
West Virginia
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Armed Forces Americas
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Date Filed:
Attach any documents you believe support your complaint.
Drop files here or
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.
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*
First
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Date
*
Date Format: MM slash DD slash YYYY
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