City Of Jefferson Ada Complaint Form

City of Jefferson

ADA Complaint Form

Name of Complainant: _______________________________________________________________

Address: __________________________________________________________________________

City: ________________________________ State: _____________ Zip Code: _________________

Home Phone: ____________________________Cell Phone: _______________________________

E-Mail Address: ____________________________________________________________________

Preferred Method(s) of Communication: ________________________________________________

__________________________________________________________________________________

I. DESCRIBE YOUR COMPLAINT OF DISCRIMINATION BASED UPON DISABILITY. Be

specific and give dates, times, and locations.

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Parent category: Business