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Thursday , July , 27 , 2017
You are here : Title VI Civil Rights  >  Complaint Form

Zia Therapy Center, Inc.

 Title VI Complaint Form

Section I

Name:

Address:

Telephone (Home/Cell):

Telephone (Work):

Email Address:

Section II

Are you filing this complaint on your own behalf: Yes o No o

*If you answered “yes” to this question, go to Section III.

If you answered “no” please enter the name and relationship of the person you are filing the complaint against:

Name:

Relationship:

If you are filing a complaint as a third party, please explain why in the space below:

Have you have obtained permission of the aggrieved party if you are filing on behalf of a third party: Yes o No o

Section III

I believe the discrimination I experienced was based on (check all that apply):

o Race o Color o National Origin

Date of Alleged Discrimination (Month, Day, Year):

Date:

Explain, as clearly as possible, that happened and why you believe you were discriminated against. Describe all persons who were involved. Include the name and contact information of the person(s) who discriminated against you (if known) as well as the names and contact information of any witnesses. If more space is needed please attach additional sheets to this form: