HomeMy WebLinkAboutTitle_VI_Complaint_FormTitle VI Complaint Form, GO Transit 1
Title VI Complaint Form
GO Transit
The following information is necessary to assist us in processing your complaint.
If you require assistance in completing this form, please contact GO Transit by
calling (920) 232-5340. The completed form must be returned to the GO Transit
– Attn: Title VI Complaints, 926 Dempsey Trail, Oshkosh, WI 54902.
The GO Transit is committed to ensuring that no person is excluded from
participation in, or denied the benefits of its services on the basis of race, color or
national origin as protected by Title VI of the Civil Rights Act of 1964, as
amended (“Title VI”).
Title VI complaints must be filed within 180 days from the date of the alleged
discrimination.
Your Name: Phone:
Street Address: City, State & Zip Code:
Person(s) discriminated against (if someone other than complainant above):
Name(s):
Street Address, City, State & Zip Code:
Which of the following best describes the reason for the alleged discrimination which took place?
(Circle one)
• Race
• Color
• National Origin (Limited English Proficiency)
Date of the incident:______________________
Please describe the alleged discrimination incident. Provide the names and titles of all GO Transit
employees involved if available. Explain what happened and whom you believe was responsible.
Please use the back of this form if additional space is required. More space is provided on next
page.
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Have you filed a complaint with any other federal, state or local agencies? (Circle one) Yes / No
If yes, list agency / agencies and contact information below:
Agency 1 Name: Contact Name:
Street Address, City, State, Zip Code:
Phone:
Agency 2 Name: Contact Name:
Street Address, City, State, Zip Code:
Phone:
I affirm that I have read the above charge and that it is true to the best of my knowledge,
information and belief:
Complainant’s Signature: Date:
For GO Transit office use only.
Date received by GO Transit:________________________
Received by:________________________________