ADA, Title VI Complaint Form : Tulsa Transit

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
- State Agency
- Local Agency
- Other
Other*
If you filed with another agency please provide the contact information for the Agency Representative:
Name

First

Last
Address

Street Address

City

State

ZIP Code
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.
Name*

First

Last
Date*

Date Format: MM slash DD slash YYYY

ADA, Title VI Complaint Form