Limited English Proficiency Complainant Form | Department Of Natural Resources Division

Instructions : Please fill out this form completely. Fields marked with a red asterisk ( * ) are required.

Complainant Name

Address

City/Town

State/Province

ZIP/Postal Code

Country

Telephone

Email Address

Are you the person (complainant) who was discriminated against?

Yes

No

Person discriminated against

Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Telephone

GADNR individual or organization you believe has discriminated :

Name

Organization

Site/ Facility/ Location

Address

City/Town

State/Province

ZIP/Postal Code

Country

Telephone Number

When did the discrimination occur? Date

Describe the act(s) of discrimination providing the name(s) where possible of the individuals who discriminated:

TERMS OF ACCEPTANCE and SIGNATURE

Electronic Signature

Electronic Signature

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