Belgrade Community Library

Empowering a community of lifelong learners

 

106 N BROADWAY

BELGRADE, MT 59714

406-388-4346

www.belgradelibrary.org

 

AMERICANS WITH DISABILITIES ACT

SERVICE DELIVERY DISCRIMINATION COMPLAINT FORM

 

(Please print.  Separate sheets of paper may be used if more space is needed.)

 

NAME:                                                                                                                                                                                                                 

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:

                                                                                                                                                                                                               

                                                                                                                                                                                                               

                                                                                                                                                                                                               

 

Signature:                                                                                                                                           Date:                                    

 

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.