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City of Titusville VI / Nondiscrimination Complaint Form
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* Indicates required question
Complainants Name:
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Your answer
Complainants Phone Number
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Your answer
Complainants Address
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Your answer
Complainant's Representatives Name, Address, Phone, and Relationship (e.g. friend, attorney, parent, etc.)
Your answer
Name and Address of Agency, Institution, or Department Whom You Allege Discriminated Against You
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Your answer
Names of the Individuals Whom You Allege Discriminated Against You
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Your answer
Discrimination Because Of:
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Race
Color
National Origin
Sex
Age
Handicap/Disability
Other
Required
Date of Alleged Discrimination:
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MM
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DD
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YYYY
Please list the names and phone numbers of any person, if known, that the City of Titusville could contact for additional information to support or clarify your allegations.
Your answer
Please explain as clearly as possible how, why, when, and where you believe you were discriminated against. Include as much background information as possible about the alleged acts of discrimination.
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Your answer
Complainants or Complainant's Representatives Signature:
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Your answer
Date of Signature:
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DD
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YYYY
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