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ADA Grievance Form

  1. Person discriminated against (if someone other than yourself):
  2. Basis for alleged discrimination (check all that apply):
  3. Have you filed this complaint with any other federal, state, or local agency; or with any federal or state court?
  4. If yes, check all that apply:
  5. Please provide information about a contact person at the agency/court where the complaint was filed:
  6. We cannot accept a complaint if it has not been signed. Please sign and date this form on the lines shown below:
  7. Electronic Signature Agreement
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
  8. Leave This Blank:

  9. This field is not part of the form submission.