PRINTABLE TITLE VI DISCRIMINATION COMPLAINT FORM
Please print out this form, fill it out and mail it to: GNHTD, ConnDOT, or the Federal Transit Administration.
Name: ______________________________________________________________
Street Address: _______________________________________________________
Apt.#: _______________________________________________________________
City or Town/State/Zip Code: ___________________________________________
Phone: ______________________________________________________________
Discrimination because of: __Race __Color __National Origin
Please provide the date(s) and location of the alleged discrimination, the name(s) of the
individual(s) who allegedly discriminated against you including their titles (if known).
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Please provide the names, addresses and telephone numbers of any witnesses.
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Explain as briefly and as clearly as possible what happened, how you feel that you were discriminated against and who was involved. Please include how other persons were treated differently from you.
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Signature/Date
You may use additional sheets of paper if necessary. Also include any written
materials pertaining to your complaint.