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Town of Truckee Title VI Complaint Form

Town of Truckee – Truckee Transit
Title VI Complaint Form
10183 Truckee Airport Road, Truckee, CA 96161; (530) 582‐7700

Complainant’s Name: _________________________________________________________________________

Street Address:_________________________________________________________________________

City/State/Zip:_________________________________________________________________________

Telephone: __________________________  Alternate Phone: __________________________

E‐Mail Address: _________________________________________________________________________

Date of Violation:__________________________ Time of Violation: __________________________

Place of Violation: _________________________________________________________________________

Bus Number: __________________________   Bus Service (Fixed Route or Dial‐A‐Ride): __________________________

I feel the discrimination I experienced was based on:  □ Race     □ Color     □ National Origin

Please provide the name(s) of the Truckee Transit employee(s) who allegedly discriminated against you, if known.

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Identify what Truckee Transit program, activity, or service you were using at the time you were allegedly discriminated against.

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Identify individuals by name, address and phone number that has information relating to the alleged violation.

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Explain what happened and why you feel you were discriminated against. Please include how other individuals were treated differently from you. Use the back of this form if you need more space.

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Signature of Complainant: __________________________ Date: __________________________