BELGRADE COMMUNITY LIBRARY

106 N BROADWAY

BELGRADE, MT 59714

388-4346

www.belgradelibrary.org

 

AMERICANS WITH DISABILITIES ACT

 

SERVICE DELIVERY DISCRIMINATION COMPLAINT FORM

 

(Please Print.  You may use separate sheets of paper if you need more space)

 

NAME:_______________________________________________________________________

 

ADDRESS:____________________________________________________________________

 

CITY, STATE, ZIP:_____________________________________________________________

 

TELEPHONE (INCLUDE AREA CODE):___________________________________________

 

Name of Department and/or employee against whom the complaint is filed: ______________________________________________________________________________

 

Description of the action or treatment which you think was discriminatory.  Include information about who, what, when, where, how, why and the names, addresses and phone numbers of any witnesses, if you know them.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Description of the relief or satisfaction you want: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

Signature______________________________________Date__________________________

 

You may call the Library Director if you would like help in filling out this form 406-388-4346

Please return the completed form to the Belgrade Community Library Director