Fillable ADA GRIEVANCE FORM FOR PUBLIC SERVICES Title II (City of College Station)

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ADA GRIEVANCE FORM FOR PUBLIC SERVICES Title II (City of College Station)

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ADA GRIEVANCE FORM
FOR PUBLIC SERVICES
Please complete, sign and submit this form within 60 calendar days
of any grievance to the address at the bottom of the page.
Full name of person submitting report:
Address:
City: State: Zip Code:
Phone: Alternate phone:
Email:
If you are reporting this grievance on someone else’s behalf, please provide their full name:
Please provide a detailed description of your grievance. If applicable, include the date, time, location, city
department(s) involved, and the desired remedy you are seeking. Add additional pages if necessary:
Has this grievance been reported to anyone else? If so, to whom?
Signature: Date:
If you need assistance, require an accessible format, or have questions about this form, please contact
the City of College Station ADA Coordinator at adaassistance@cstx.gov or 979.764.3509.
Title II of the Americans With Disabilities Act,
Section 504 of the 1973 Rehabilitation Act
Physical Address:
1101 Texas Ave.
College Station, TX 77845
Mailing Address:
P.O. Box 9960
College Station, TX 77842
ADA COORDINATOR
cstx.gov/ada
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ADA GRIEVANCE FORM FOR PUBLIC SERVICES Title II (City of College Station)

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Completed 27 January 2021

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