ADA COMPLAINT FORM

ADA COMPLAINT FORM
Name

First NameLast Name
Date

MonthDayYear
Date
Date

MonthDayYear
Date
Representative:(on behalf of Complainant)

First NameLast Name
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Email*
example@example.com
Please check one:

ComplaintConcern
Please Note: Complaints are public record.
Details: Please use the details section to give information about the alleged discrimination such as name, address, phone number of complainant and location, date and description of the problem. Please use back of form if necessary. Alternative means of filing complaints, such as personal interviews or a audio recording of the complaint will be made available for persons with disabilities upon request.
Name
Date

MonthDayYear
Date
Please mail or deliver this form to: Celene E. Steckel, Director Department of Citizen Services 10 Distillery Drive, Suite 101 Westminster, MD 21157
Please verify that you are human*
Should be Empty: