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.
Email address *
Complainant Name *
Street Address *
City *
State *
Zip Code *
Phone Number *
Please provide the names, address and phone number of any additional complainants:
Are you filing this complain on your own behalf? *
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.
Location of Incident
Date of Incident
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Discrimination Based On (please check all that apply): *
Required
Please explain how, when and where the alleged discrimination occurred. Include as much background information as possible about the alleged acts of discrimination. *
Name of agency which alleged complaint is against: *
Angency Contact's Name *
Employee's Title *
Employee's Telephone *
Employee's Email *
Have you previously filed a Title VI complaint with this agency? *
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 *
If yes, please check all that apply
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
Complainant's Signature (Typed Name)
Today's Date
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DD
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