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2. Americans with Disabilities Act Complaint Form
   5 Town Dial-a-Ride is committed to ensuring that no person is denied access to its services, programs, or activities on the basis of their disabilities, as provided by title II of the Americans with Disabilities Act of 1990 (“ADA”). ADA complaints must be filed within 180 days from the date of the alleged incident.
   
   The following information is necessary to assist us in processing your complaint. If you require any assistance in completing this form, or if you would like to make a verbal complaint, please contact the “enter Contact information”.
4. Complainant
5. Phone
7. Address
9. City
10. State
11. Zip Code
13. Date of Incident
    Date of Incident
15. Please describe the alleged discriminatory incident, including the location(s), if applicable. Provide the names and titles of 5 TOWN Dial-A-Ride employees involved, if available.
17. Have you filed a complaint with any other federal, state, or local agencies?

    1. Yes

    1. No
19. Agency Contact Name
21. Street Address, City, State, Zip Code Phone
23. Agency Contact Name
25. Electronic Signature*

    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.

    1. I agree
    2. I do not agree
27. I affirm that I have read the above charge and that it is true to the best of my knowledge, information, and belief.
29. Date
    Date
30. Name of Complainant
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field