ADA Complaint Form

Atlanta Regional Commission (ARC) 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 VI of the Americans with Disabilities Act of 1990.

Any person(s) or organization(s) believing they have been a victim of discrimination based on a disability may file a complaint with the Office of Human Resources, by completing the form below or contacting HR at 404-463-3100.

This complaint form can be provided in an alternative format upon request.

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

Phone (Home)(Required)

Phone (Work)(Required)

Email(Required)

Location of Incident(Required)

Date of Incident(Required)

Are you filing this complaint on your own behalf?(Required)

Yes

No

Please supply the name and relationship of the person for whom you are complaining:(Required)

Please explain why you have filed for a third party:(Required)

Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party.(Required)

Yes

No

Please briefly describe what happened and why you believe you were discriminated against. Describe all persons who were involved. Include the name and contact information of the person(s) who discriminated against you (if known) as well as names and contact information of any witnesses.(Required)

Complaint Acknowledgement(Required)

I certify that the information provided is accurate to the best of my knowledge. I understand and consent to the disclosure of information contained in this complaint to appropriate members and witnesses interviewed for the purpose of investigating this complaint.

Signature(Required)