ADA Discrimination Complaint Form

Instructions for ADA Complaint Form

Please fill out this form completely, sign and mail, fax, or email to:

Gladwin City County Transit ADA Coordinator
615 Weaver Court
Gladwin, MI 48624
989-426-5947 Fax
[email protected]

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Complainant's Name:*

First Last

Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Telephone:

Mobile Phone:

Email:*

Person discriminated against (if other than the complainant):

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Date the discrimination occurred:*

Describe the acts of discrimination, providing the name(s) where possible of the individuals who discriminated:*

Signature*

Date of Signature:*