RAY COUNTY TRANSPORTATION, INC. TITLE VI COMPLAINT FORM

“No person in the United States shall, on the basis of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.”

If you feel that you have been discriminated against in the provision of transportation services, please provide the following information to assist us in processing your complaint. Should you require any assistance in completing this form or need information in alternate formats, please let us know.

Please mail or return this form to:

Janine Clampitt, Director
Ray County Transportation, Inc.
PO Box 382/213 Valley Drive
Richmond, MO 64085
Email: janine_r.bus@mchsi.com
Fax: (816) 776-3161

PLEASE PRINT
1. Complainant’s Name:
Address:
City:
State:
Zip Code:
Telephone (include area code):
Home: 
Cell:
Work:
 Electronic mail (e-mail) address:
Do you prefer to be contacted by this e-mail address? ( ) YES ( ) NO

2. Accessible Format of Form Needed? ( ) YES specify:_________________________ ( ) NO

3. Are you filing this complaint on your own behalf? ( ) YES If YES, please go to question 7.
( ) NO If no, please go to question 4

4. If you answered NO to question 3 above, please provide your name and address.
Name of Person Filing Complaint:
Address:
City: State: Zipcode:
Telephone (include area code):
Home:
Cell: 
Work:
Electronic mail (e-mail) address:
Do you prefer to be contacted by this e-mail address? ( ) YES ( ) NO

5. What is your relationship to the person for whom you are filing the complaint?

6. Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party. ( ) YES, I have permission. ( ) NO, I do not have permission.

7. I believe that the discrimination I experienced was based on (check all that apply):
( ) Race ( ) Color ( ) National Origin (classes protected by Title VI)
( ) Other (please specify)

 
Home | Privacy Policy | Contact Us | Accessibility Statement
© 2009 Ray County Transportation. Phone: 1-888-776-80581-888-776-8058 FREE

FREE HIT COUNTERS