2. Complainant Name*
4. Address*
6. City*
7. State*
8. Zip*
10. Phone Number*
11. Email Address*
13. Please provide a detailed description of your complaint of discrimination based upon disability*
15. Place of complaint

    Please include an address or description of where this complaint occurred.

17. Persons named in complaint

    Please list names of or, or describe, all persons associated with your complaint.

19. Evidence and documentation

    Please describe any evidence or documentation related to this incident.

21. Supporting documents

    Please attach any documents, photos, etc. related to this incident. These fields are optional. If you only have one document to attach, please use the "Document 1" field.

23. Document 1
25. Document 2
27. Document 3
29. Requested modifications or improvements

    Please describe how this situation might be improved.

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31. 1. Receive an email copy of this form.
32. Email address

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33. Submit

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