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2. City of Nashua ADA Title II Grievance Form

   AMERICANS WITH DISABILITIES ACT TITLE II – GRIEVANCE FORM

4. Today’s Date:*
   Today’s Date:
6. Contact Information:
8. Complainant Name*
9. Email Address
11. Address*
13. City*
14. State*
15. Zip Code*
17. Phone Number*
19. Individual Discriminated Against (if other than complainant):
21. Full Name
22. Email Address
24. Address
26. City
27. State
28. Zip Code
30. Phone Number
32. Alleged Violation:
34. Date(s) of occurrence:*
    Date(s) of occurrence: Start Date

    —

    Date(s) of occurrence: End Date

    If occurrence happened only once in a single day, put the same date in both boxes above.

35. 2nd Date(s) of occurrence (optional):
    2nd Date(s) of occurrence (optional): Start Date

    —

    2nd Date(s) of occurrence (optional): End Date
37. Describe violation and City Department involved:*
39. What efforts have been made to resolve this complaint?*
41. 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.

43. Supporting documentation (1)
44. Supporting documentation (2)
45. Supporting documentation (3)
47. Has complaint been filed with State or Federal Agency:

    1. Yes
    2. No
    3. Not yet / In progress
49. Name of Agency:
50. Contact Person:
51. Date Filed:
    Date Filed:
53. 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.

    1. I agree.
55. Electronic Signature*
Leave This Blank:


57. 1. Receive an email copy of this form.
58. Email address

    This field is not part of the form submission.

59. Submit

* indicates a required field