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City of Fairmont Discrimination Complaint Form

Complainant Information

Relationship of Preparer to Complainant (if applicable)

Phone Number of Complainant

Email of Complainant

Nature of Complaint and Incident Details

Please provide a complete description or narrative of the specific complaint, including any incident, barrier, or perceived denial of benefit of any service, program, or activity.

Complaint could be made about discrimination based on race, color, or national origin (including language), disability, sex, age, or religion.

There will be a space to attach any additional pages or documents if needed.

Description or Narrative:

Date of Alleged Incident:

Please specify any location(s) or department related to the complaint (if applicable):

Please state what you think should be done to resolve the complaint:

Name(s) and contact info of any person known to be a witness to the alleged incident:

Signature of Complainant

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Upload File(s) if needed:

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Upon submission this form will be delivered to the ADA & Nondiscrimination Coordinator. A response can be expected as per the guidelines found in the City of Fairmont's Nondiscrimination Policy.

City of Fairmont Discrimination Complaint Form

Complainant Information

Full Name of Complainant

Person Preparing Complaint (if different from Complainant)

Full Address of Complainant

Nature of Complaint and Incident Details

Date of Alleged Incident:

Signature of Complainant

Upload File(s) if needed: