Fillable UNION COUNTY, NORTH CAROLINA AMERICAN WITH DISABILITIES ACT (Union County Government)

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UNION COUNTY, NORTH CAROLINA AMERICAN WITH DISABILITIES ACT (Union County Government)

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UNION COUNTY, NORTH CAROLINA
AMERICAN WITH DISABILITIES ACT COMPLAINT FORM
Date: _______________
Name: _________________________________ Telephone Number: ____________________
Address: _____________________________________________________________________
City: __________________________ State: ________________ Zip Code _______________
Please describe your concern or complaint and indicate the approximate time, date and location
of the occurrence. (If additional space is needed, please attach extra sheets)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
What do you think would resolve the problem or complaint?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
PRIVACY STATEMENT: The respondent is authorized to receive a copy of my complaint.
I affirm that I have read the above information and that it is true to the best of my knowledge,
information and belief.
Signature of Complainant ________________________________________________________
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UNION COUNTY, NORTH CAROLINA AMERICAN WITH DISABILITIES ACT (Union County Government)

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Completed 18 July 2020

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