ADA Complaint Form

EAST BRUNSWICK ADA COMPLAINT FORM

Americans with Disabilities Act Complaint Form

East Brunswick Township is committed to ensuring that no person is denied access to its services, programs, or activities on the basis of their disabilities, as provided by title II of the “Americans with Disabilities Act of 1990” (“ADA”). ADA complaints must be filed within 180 days from the date of the alleged incident.The following information is necessary to assist us in processing your complaint. If you require any assistance in completing this form, or if you would like to make a verbal complaint, please contact the Director of the Department of Planning and Engineering, at 732-390-6870.

Complainant:

Phone:

Street Address:

City, State, Zip Code

Alt Phone:

Person Preparing Complaint (if different from Complainant):

Phone:

Street Address, City, State, Zip Code:

Date of Incident: _________________________

Please describe the alleged discriminatory incident, including the location(s), if applicable. Provide the names and titles of East Brunswick Township employees involved, if available. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Have you filed a complaint with any other federal, state, or local agencies? Yes/No (Circle One).

If so, list agency/agencies and contact information below:               _____________________________________________________________________________________________

Agency Contact Name: _____________________________________________________________________________________________

Street Address, City, State, Zip Code, Phone: _____________________________________________________________________________________________

Agency Contact Name: _____________________________________________________________________________________________

I affirm that I have read the above charge and that it is true to the best of my knowledge, information, and belief.

_______________________________________         ____________________________________

Complainant’s Signature                                                    Date

_______________________________________

Print or Type Name of Complainant

Date Received: __________________________         Received By: ________________________