§ 34.03 ADA COMPLAINT FORM.

 

CITY OF BIG TIMBER, MONTANA ADA COMPLAINT FORM   COMPLAINANT’S NAME:                                                                                                  MAILING ADDRESS:                                                                                                                                                                                                                                                                                                                                                                                                    TELEPHONE NUMBER:                                                                (8:00 am to 5:00 pm, Mon-Thurs & 8:00 am to 3 pm Friday)   PLEASE DESCRIBE THE ALLEGED DISCRIMINATORY ACTION OR DENIAL OF SERVICE. Please provide sufficient details. Include: description of alleged discriminatory action, names, dates, places, actions/events, witnesses, etc.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  [          ] CHECK HERE if additional pages are attached   PLEASE SPECIFY WHAT CORRECTIVE ACTION YOU ARE SEEKING:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              [          ] CHECK HERE if additional pages are attached. _________________________________________________________________________ SIGNATURE OF PERSON MAKING COMPLAINTDATE   COMPLAINTS SHOULD BE ADDRESSED TO: (Name and Address of ADA/Section 504 Coordinator). Telecommunications Device for the Deaf - TDD: [phone]. Dial 711 or 1-800-253-4091 to use the Montana Relay Service.   *    *      *      *      *      *      *      * FOR AGENCY USE ONLY _________________________________________________________________________ SIGNATURE OF PERSON MAKING COMPLAINT _________________________________________________________________________ DATE ____________________________________________ TITLE

 

(Res. 914, passed 8-15-2011)