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Maryland Department of Natural Resources Complaint of Discrimination Form
If you believe that you have been discriminated against with respect to a Maryland Department of Natural Resources program or activity, please fill out this form to file a formal complaint.
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* Indicates required question
Email
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Your email
Complainant Name
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Your answer
Street Address
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Your answer
City
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Your answer
State
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Your answer
Zip Code
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Your answer
Phone Number
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Your answer
Please provide the names, address and phone number of any additional complainants:
Your answer
Are you filing this complain on your own behalf?
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Yes
No
If you answered "Yes" skip this question. If you answered "No" to this question, please provide the following: The name and relationship; Why you have filed for this person; and confirm that you have permission of the aggrieved party.
Your answer
Location of Incident
Your answer
Date of Incident
MM
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DD
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YYYY
Discrimination Based On (please check all that apply):
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Race
Color
National Origin
Sex
Age
Handicap/Disability
Retaliation
Other:
Required
Please explain how, when and where the alleged discrimination occurred. Include as much background information as possible about the alleged acts of discrimination.
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Your answer
Name of agency which alleged complaint is against:
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Your answer
Angency Contact's Name
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Your answer
Employee's Title
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Your answer
Employee's Telephone
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Your answer
Employee's Email
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Your answer
Have you previously filed a Title VI complaint with this agency?
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Yes
No
Have you ever filed a Title VI complaint, based on the facts alleged in complaint you are making now with any other Federal, State, or local agency, or with any Federal or State Court
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Yes
No
If yes, please check all that apply
Federal Agency
Federal Court
State Court
State Agency
Local Agency
Please provide a contact person at the agency or court where the complaint was filed. Include name, title, agency address and phone for each complaint filed
Your answer
Complainant's Signature (Typed Name)
Your answer
Today's Date
MM
/
DD
/
YYYY
Send me a copy of my responses.
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