Lowell Regional Transit Authority

978-452-6161

LRTA Title VI Complaint Form

Title VI and Related Statutes
DISCRIMINATION COMPLAINT AGAINST THE
Lowell Regional Transit Authority

Name:

Telephone (home):

Telephone (work):

Address:

City, State, Zip Code:

Name of LRTA Person, Organization, or Agency that You Believe Discriminated Against You:

Address:

City, State, Zip Code:

Date of Alleged Incident:

You Were discriminated against on the basis of:

□ Race

□ Color

□ Age

□ Family Status

□ Religion

□ Retaliation

□ National Origin (Language)

□ Sex

□ Disability

□ Other

Explain as briefly and clearly as possible what happened and how you were discriminated against. Indicate who was involved. Be sure to include how other persons were treated differently than you. Also attach any written material pertaining to your case:

Signature:

Date:

 

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