Centro ADA Complaint Form

1. First Name *

2. Last Name *

6. Zip Code *

8. Phone Number (with area code) *

If Other, please describe.

If not, please provide the name of and your relationship to the person for whom you are filing the complaint.

12. Date of alleged discrimination on the basis of disability *

13. Time of Day *

14. Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons who were involved. Include names and contact information of the person(s) who discriminated against you (if known) as well as the names and contact information of any witnesses. *

15. Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State Court?

Yes (specify below the name of the agency or court where you have filed this complaint)
No

16. Name of agency or court where complaint was filed.

Please provide information about a contact person at the agency/court where the complaint was filed.

21. Phone Number

Attach File

You may attach any written materials or additional information you feel is relevant to your complaint.

ADA Complaint Form

Instructions