2. SIERRA COUNTY TRANSPORTATION COMMISSION TITLE VI COMPLAINT FORM
4. First Name
5. Last Name
7. Address1
9. City
10. State
11. Zip
13. Telephone (Home)
14. Telephone (Work)
15. Email
17. I belive that discrimination was based on (check all that apply):

    1. Race
    2. Color
    3. National Origin
    4. Other
18. Date of Alleged Discrimination
    Date of Alleged Discrimination

    Date of Alleged Discrimination
20. Explain as clearly as possible what happened and how you were discriminated against. Indicate who was involved. Be sure to include the names and contact information of any witnesses. If more space is needed please use the back of the form.
22. Have you filed this complaint with any other federal, state, or local agency, or with any federal or state court?

    1. Yes

    1. No
24. If Yes, check all that apply

    1. Federal Agency ____________
    2. Federal Court ______________
    3. State Court ________________

    1. State Agency _______________
    2. Local Agency _______________
26. Please provide information about a contact person at the agency/court where the complaint was filed.
28. First Name
29. Last Name
31. Title
32. Agency
34. Address
36. Telephone
38. You may attach any written materials or other information that you think is relevant to your complaint
39. Signature
40. Date
    Date

    Date
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit Submit and Print

* indicates a required field