Forms • Battle Creek, MI • CivicEngage

Battle Creek Transit (BCT) Title VI Complaint Form

Leave This Blank:

The following information is necessary to assist us in processing and investigating your complaint. If you require assistance in completing this form, then please contact the Title VI Coordinator at (269) 966-3588.

Section I:

Name:

Phone:

Phone (Other):

Address:

City:

State:

Zip:

E-mail:

Section II:

Are you filing this complaint on your own behalf?

*If you answered “yes” to this question, then skip to Section III.

If not, then please supply the name and relationship of the person for whom you are complaining:

Please explain why you have filed for a third party:

Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party.

Section III:

Which of the following best describes the reason you believe the alleged discrimination was based on? (Check all that apply)

	Race
	Color

National Origin

Date of Alleged Discrimination (month/day/year):

Explain as clearly as possible what happened and how you believe you were discriminated against. Describe all persons who were involved, and provide the names and title of all BCT employees involved, if possible. Be sure to include the names and contact information of any witnesses.

Witnesses to alleged discrimination:

Name:

Contact Info:

Name:

Contact Info:

Name:

Contact:

Section IV:

Have you filed this complaint with any other Federal, State, or local agency; or with any Federal or State court?

If yes, check all that apply:

	Federal agency
	Federal court
	State agency

	State court
	Local agency

Please provide information about a contact person at the agency/court where the complaint was filed.

Name:

Title:

Address:

City:

State:

Zip:

Phone Number:

Section V:

Name of the agency complaint is against:

Contact person:

Title:

Telephone Number:

You may attach any written materials or other information that you think is relevant to your complaint. I affirm that I have read the above charge and that it is true to the best of my knowledge, information and belief.

Convert to PDF?
(DOC, DOCX, XLS, XLSX, TXT)

Type Full Name:*

Date:*

* indicates required fields.

Live Edit

Contact Us

Quick Links

Helpful Links