Discrimination Complaint Form

Your Name*
Phone #*
Email*
Name of Person(s) that discriminated against you*
Address (Street No., P.O. Box, Etc.)*
City, State, Zip*
Location and Position of Person (If Known)
City, State, Zip*
Discrimination Because of
- Race/Color
- Age
- Religion
- Sex
- National Origin
- Disability
- Retaliation
Date(s) of Alleged Incident(s)*
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*
HBFAAA 240 Wood St., P.O. Box 46 Bedford, PA 15522 Phone (814) 623-8148 Fax (814) 623-5929
Federal Motor Carrier Safety Administration 1200 New Jersey Avenue, SE Washington, DC 20590 Attn: Title VI or ADA Program Coordinator