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Complaint of Discrimination Form

Name:___________________________________________    Telephone Number: __________________________

Address: ______________________________________  City: ___________________________ Zip: __________

Basis of Complaint: __Race  __Color __National Origin __Disability __Other ______________________________

Type of Complaint: __Program __Service __Benefit __Activity

Who allegedly discriminated against you? Name: _____________________________________________________

Address: ____________________________________________________ Telephone Number: _________________

If an organization, what is the name of the organization? ________________________________________________

Address: ____________________________________________________ Telephone Number: _________________

Name of Contact: _____________________________________

How were you discriminated against? _______________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

Where did the alleged discrimination occur? _________________________________________________________

______________________________________________________________________________________________

Date(s) and time(s) discrimination occurred? First time? ________________________________________________

Second time? _________________________________ Third Time? _______________________________________

Were there any witnesses to the discrimination?

Name: ________________________ Title: ______________ Telephone: ___________________________________

Name: ________________________ Title: ______________ Telephone: ___________________________________

Name: ________________________ Title: ______________ Telephone: ___________________________________

What can the bus company do to resolve the complaint?

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

Have you filed your complaint with anyone else? Who? ________________________________________________

When? ____________________ Complaint Number (if known): _________________

Do you have an attorney in this matter? Name: _______________________________________________________

Address: ______________________________________________ Telephone: ______________________________

When did you acquire the attorney? _______________________________

Your Signature: _________________________________ Today’s Date: _________________________

Please submit your complaint to: Trailways Compliance Officer

via U.S. Mail: 499 Hurley Ave, Hurley, NY 12443
or Fax: (845) 339-5222
or Telephone: (845) 339-4230, Ext. 168
or Email: BCook@TrailwaysNY.com

Title VI and ADA Policy StatementTitle VI Complaint Procedure