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ADA Title II Grievance Form

  1. City of Nashua ADA Title II Grievance Form


  2. Contact Information:
  3. Individual Discriminated Against (if other than complainant):
  4. Alleged Violation:
  5. If occurrence happened only once in a single day, put the same date in both boxes above.

  6. Please include a copy of supporting documentation (PDF or JPG Only)

    ONLY PDF or JPG image files are accepted for supporting documentation uploads. Save files as PDF, scan to PDF or JPG, or provide a clear JPG picture of letters, e-mails, notes, etc.

  7. Has complaint been filed with State or Federal Agency:
  8. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  9. Leave This Blank:

  10. This field is not part of the form submission.