Title VI Discrimination Complaint Form

Complainant's Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone
Email
Discrimination because of
Please provide the date(s) and location of the alleged discrimination, the name(s) of the individual(s) who allegedly discriminated against you including their titles (if known).
Please provide the names, addresses, and telephone numbers of any witnesses.
Explain as briefly and as clearly as possible what happened, how you feel that you were discriminated against, and who was involved. Please include how other persons were treated differently from you.

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