ADA Complaint Form
Virgin Islands Port Authority ADA Complaint Form Virgin Islands Port Authority Gateways to the USVI’s Economy VIRGIN ISLANDS PORT AUTHORITY AMERICAN DISABILITIES ACT COMPLAINT FORM Name of Complainant: Sex: Race /Ethnic Group: Mailing Address: City: Zip: Home Telephone: Cell Phone: Work Telephone: Email Address: Accessible Format ⃞ Large Print ⃞ Audio Tape ⃞ TDD Preferred: ⃞ Other SECTION II Is this an ADA complaint for discrimination based on a disability? ⃞ Yes ⃞No Are you filling this complaint on your own behalf? ⃞ Yes ⃞No [If you answered “yes” to this question, go to Section III.] If not, please supply the name and relationship of the person for whom you are filing this complaint: Name: Relationship: 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: ⃞ Yes ⃞ No SECTION III: Incident Information Date of Alleged Incident: ________________________ Time of Day: _______________________ Explain as clearly as possible what happened: Describe all persons involved. …
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Virgin Islands Port Authority ADA Complaint Form Virgin Islands Port Authority Gateways to the USVI’s Economy VIRGIN ISLANDS PORT AUTHORITY AMERICAN DISABILITIES ACT COMPLAINT FORM Name of Complainant: Sex: Race /Ethnic Group: Mailing Address: City: Zip: Home Telephone: Cell Phone: Work Telephone: Email Address: Accessible Format ⃞ Large Print ⃞ Audio Tape ⃞ TDD Preferred: ⃞ Other SECTION II Is this an ADA complaint for discrimination based on a disability? ⃞ Yes ⃞No Are you filling this complaint on your own behalf? ⃞ Yes ⃞No [If you answered “yes” to this question, go to Section III.] If not, please supply the name and relationship of the person for whom you are filing this complaint: Name: Relationship: 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: ⃞ Yes ⃞ No SECTION III: Incident Information Date of Alleged Incident: ________________________ Time of Day: _______________________ Explain as clearly as possible what happened: Describe all persons involved. Include names and contact information of the person(s) who discriminated against you (if known) as well as the names and contact information of any witnesses. If more space is needed, please attach additional sheets. Virgin Islands Port Authority ADA Complaint Form Virgin Islands Port Authority Gateways to the USVI’s Economy SECTION IV: Administration Did you file this complaint with another Federal or local agency; or with a Federal or local court? ⃞Yes ⃞No If answer is yes, check each agency complaint was filed: Federal Agency ⃞ Federal Court ⃞ Local Court ⃞ Local Agency Date filed Please provide contact person information for the agency or court where the complaint was filed: Name: Telephone: Address: City: Zip: Please sign and date this complaint form below. Attach any supporting document(s) you think is relevant to your compl aint. Signature: Date: This form can be submitted in person, mail, or email to: Daphne Durand Mayers Legal & Programs Management Officer 8074 Lindbergh Bay St. Thomas, VI 00802 Phone: 340.714.6402 Email: dmayers@viport.com