Title VI Complaint Form

Midwest Center for Traffic Safety

Title VI Program Complaint Form

MCTS is committed to ensuring that no person is excluded from participating in or denied the benefits of its services on the basis of race, color, sex, age, national origin or disability, as provided by Title VI of the Civil Rights Act of 1964 and related anti-discrimination statutory and regulatory authorities. Title VI Program complaints must be filed within 180 days from the date of the alleged discrimination. The following information is necessary to assist us in processing your complaint. If you require any assistance in completing this form, please contact the Title VI Program Coordinator.

The signed and completed form must be sent to MCTS either via email at mfisher@midwesttrafficsafety.org or by mail to Midwest Center for Traffic Safety , 301 Congress Parkway, Suite 1306, Crystal Lake, IL 60039

First name

Last name

Address

Phone

Person Discriminated Against (if someone other than complainant)

Address

What is the date of the alleged discrimation?

In your own words, describe the alleged discrimination. Explain what happened and what policy, program, activity, or person you believe was discriminatory.

Have you filed this complaint with any other federal, state, territory or local agency, or with any federal or state court?

Yes

If so, please provide the contact person at the agency/court where the complaint was filed.

Signature

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Midwest Center for Traffic Safety

Title VI Program Complaint Form

First name

Last name

Address

Phone

Person Discriminated Against (if someone other than complainant)

Address

What is the date of the alleged discrimation?

In your own words, describe the alleged discrimination. Explain what happened and what policy, program, activity, or person you believe was discriminatory.

Have you filed this complaint with any other federal, state, territory or local agency, or with any federal or state court?

Yes

If so, please provide the contact person at the agency/court where the complaint was filed.

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.