Title VI Complaint Form - Lake Erie Transit

Complainant’s Name*
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
What was the discrimination based upon?*
Check all that apply.
- Race/Color
- Income
- Religion
- Disability
- National Origin
- Sex
- Sexual Orientation
- Other
If other above, please describe.
Witness 1
Please provide Witness contact information (if any).
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Witness 2
Please provide Witness contact information (if any).
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Describe the incident*
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