Belgrade Community Library
Empowering a community of lifelong learners
106 N BROADWAY
BELGRADE, MT 59714
AMERICANS WITH DISABILITIES ACT
SERVICE DELIVERY DISCRIMINATION COMPLAINT FORM
(Please print. Separate sheets of paper may be used if more space is needed.)
ADDRESS: CITY, STATE, ZIP:
TELEPHONE (INCLUDE AREA CODE):
EMAIL ADDRESS (OPTIONAL):
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, and why; as well as the names, addresses and phone numbers of any witnesses, if you know them.
Description of the relief or satisfaction you would like:
You may call the Library Director at (406)388-4346 if you would like help in filling out this form.
Please return the completed form to the Belgrade Community Library Director.