Title Vi Complaint Form s1

TRADE INDUSTRIES TITLE VI COMPLAINT FORM

"No person in the United States shall, on the ground 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:

Mark Auten TRAD E Industr ies P.O. Box 70, McLeansboro, IL 62859 [email protected] phone 618-643-4321 , ext. 701 fax 618-643-4230 Name: City: Address: ZIP: State: E-mail: Telephone: Accessible format of Form Needed? Check all that apply OOther: 0Large Print OAudio Tape OTDD Are you filling out this complaint on your own behalf? ONo Na me of per so n fili ng co mp lai nt: Address: City: State: Z a I t P i : o T e n l s e h p i h p o

n e t : o E - t m h a i i s l : p e Y r o s u o r n : r Have e y l o u e ONo ? Explain as clearly as possible what The discrimination alleged was on the basis of (check happened and why you believe you were all that apply) discriminated against Describe all persons involved, include name and ORace OColor ONational contact information of persons who Origin OOther: Click here to enter text. discriminated against you (if known) Date of alleged discrimination: Click l1ere to enter text. W Please list any and all witness' names h and contact information. e Click here to enter text. r What type of corrective action would e you like to see taken? Click here to enter text. d Have you filed a complaint with any i other Federal,State or local agency/court? d :JYes (check all that apply) a OFed.Agen OFed. Court: Click l cy: Click here to enter text. No l here to enter text. OState Court e g 0State agency: e Click here d to enter text. d DLocal Agency: Click here to enter text. i s DLocal Court c Please attach additional r documentation as necessary. Sign i and date below: m i n x a Printed Name t i o n t a k e p l a c