Laserfiche WebLink
BK:00027 PG - 0029 <br />Discrimination Complaint Form <br />Page 2 <br />Have you filed, or intend to file, a complaint regarding the matter raised with any of the following? If yes, please provide the filing dates. Check <br />all that apply. <br />❑ US Equal Employment Opportunity Commission Date: <br />❑ Federal Highway Administration Date: <br />❑ US Department of Transportation Date: <br />❑ Federal or State Court Date: <br />❑ Other Date: <br />Have you discussed the complaint with any NCDOT representative? If yes, provide the name, position, and date of discussion. <br />Please provide any additional information that you believe would assist with an investigation. <br />Briefly explain what remedy, or action, you are seeking for the alleged discrimination. <br />**WE CANNOT ACCEPT AN UNSIGNED COMPLAINT. PLEASE SIGN AND DATE THE COMPLAINT FORM BELOW. <br />COMPLAINANT'S SIGNATURE <br />DATE <br />MAIL COMPLAINT FORM TO: <br />County of Lee Transit System <br />Mailing: Location: <br />1615 S. Third Street 1615 S. Third Street <br />Sanford, NC 27330 Sanford, NC 27330 <br />FOR MORE INFORMATION VISIT THE WEB SITE: <br />www.ncdot.gov/business/ocr <br />or call <br />919- 508 -1808 or 800 - 522 -0453 <br />FOR OFFICE USE ONLY <br />Date Cosnpla�trt "Received: <br />Prooess�dby=. " <br />Referred to:. CIFKW.A ❑FTA []FAA ❑USDOT ❑DOJ Date Referred: <br />17 <br />