Civil Rights Complaint Form
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1 Civil Rights Complaint Form It is the policy of the Greater Derry Salem Cooperative Alliance for Regional Transportation (CART) to uphold and assure full compliance with Title VI of the Civil Rights Act of 1964, The Civil Rights Restoration Act of 1987, and all related statutes. Title VI and related statutes prohibit discrimination in Federally assisted programs and require that no person in the United States of America, shall on the grounds of race, color, national origin, sex, age, religion or disability be excluded from the participation in, be denied the benefits of, or be otherwise subjected to discrimination under any program or activity receiving Federal assistance. Any individual, group of individuals or entity that believes they have been subjected to discrimination prohibited under Title VI and related statutes in receiving CART services may file a written complaint to the following address: Title VI Coordinator Cooperative Alliance for Regional Transportation 33 Geremonty Drive Salem, NH Phone: (603)
2 More information about transit-related civil rights requirements may be found on the FTA s website at Note: Apart from the form, on separate pages, please describe your complaint. You should include specific details such as names, dates, times, route numbers, witnesses, and any other information that would assist us in our investigation of your allegations. Please also provide any other documentation that is relevant to this complaint. Important: We cannot accept your complaint without a signature, so please sign on the last page of the form after printing out. 2
3 Section I I believe that I have been (or someone else has been) discriminated against on the basis of: Race / Color / National Origin Disability Not Applicable Other (specify): I believe that CART has failed to comply with the following program requirements: Disadvantaged Business Enterprise (DBE) External Equal Employment Opportunity Not Applicable Other (specify): Section II Name: Street Address: 3
4 City: State: Zip Code: Home Phone: Cell Phone: Address: Accessible format requirements: Large Print Not Applicable Other (specify): Section III Are you filing this complaint on your own behalf? Yes No 4
5 If not, please supply the name and relationship of the person for whom you are filing this complaint: Please explain why you have filed for a third party: Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party: Yes No Please sign here: Date: Note: We cannot accept your complaint without a signature. 5
6 Derechos Civiles Formulario de Queja Es la política de la Alianza Cooperativa para Transporte Regional (CART) de Gran Derry Salem para mantener y asegurar el pleno cumplimiento con el Título VI de la Ley de Derechos Civiles de 1964, La Ley de Restauración de Derechos Civiles de 1987, y todas las leyes relacionadas. Estatutos Título VI y estatutos relacionados prohíben la discriminación en los programas de asistencia federal y requieren que ninguna persona en los Estados Unidos de América, será por motivos de raza, color, origen nacional, sexo, edad, religion o discapacidad excluido de la participación en, será negado el beneficios de, o será de otra manera sometido a discriminación en cualquier programa o actividad que reciba asistencia federal. Cualquier persona, grupo de personas o entidad que crea que ha sido objeto de una discriminación prohibida por el Título VI y los estatutos en la recepción de los servicios de CART, puede presentar una denuncia por escrito a la siguiente dirección: Coordinador del Título VI Alianza Cooperativa de Transporte Regional 33 Geremonty Drive 6
7 Salem, NH Teléfono: (603) Más información sobre los requisitos de derechos civiles relacionados con el tránsito se puede encontrar en la página web del TLC en Nota: Aparte de la forma, en páginas separadas, por favor describa su denuncia. Usted debe incluir detalles específicos tales como nombres, fechas, horarios, números de ruta, testigos y cualquier otra información que nos pueda ayudar en nuestra investigación de sus denuncias. Sírvanse proporcionar también cualquier otra documentación que sea relevante en esta denuncia. Importante: No podemos aceptar su denuncia sin firma, así que por favor firme en la última página del formulario después de imprimir. 7
8 Sección I Creo que he sido (o alguien más lo ha sido) discriminado sobre la base de: aza / color / Origen Nacional Creo que CART ha dejado de cumplir con los siguientes requisitos del programa: Igualdad de Oportunidades en el Empleo Externo Sección II Nombre: Dirección: Ciudad: Estado: 8
9 Código Postal: Teléfonos: Casa: Celular: Dirección De Correo Electrónico: Requisitos de formato accesible: Otros (especificar): Sección III Está presentando esta denuncia en su propio nombre? 9
10 Si no es así, por favor proporcione el nombre y la relación de la persona para la cual usted está presentando esta denuncia: Por favor, explique por qué usted ha presentado para un tercero: Por favor, confirma que ha obtenido el permiso de la parte perjudicada, si usted está presentando en nombre de un tercero: Por favor, firme aquí: Fecha: Nota: No podemos aceptar su denuncia sin una firma. 1 0
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MISSISSIPPI EMPLOYEES
1961 Diamond Springs Road Virginia Beach, VA 23455 Phone (757) 460-6308 Fax (757) 457-9345 MISSISSIPPI EMPLOYEES MANCON Employees, Included in this packet is the following information: 1. Job Insurance
Level 1 Spanish, 2013
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