Customer Complaint Form -Greater Portland Transit, ME

Date

Section I: Contact Information

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Where you wish to be contacted

Email(Required)

Enter Email Confirm Email

Accessible Format Requirements

Large Print

Audio

Other

Other Accessible Format

Section II: Type of Complaint

Type of Complaint(Required)

General Complaint or Concern (Bus service, schedule or specific incident)

Civil Rights / Title VI Complaint (Discrimination based on race, color or national origin)

ADA Discrimination (Discrimination based on a disability)

Are you filing this complaint on your own behalf?(Required)

Yes

If not, 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.

Yes

Section III: Details of Complaint or Incident

Please select a “type of complaint” in Section II before proceeding to Section III.

1. General Complaint, Concern or Incident

Date of Incident

Time of Incident

Bus #

Route #

Inbound/Outboud

Inbound

Outbound

Driver # or Information

Additional information (location, details, witnesses, illustrations, etc.)

2. Civil Rights / Title VI Complaint

Discrimination based on (check all that apply)

Race

Color

National Origin

Explain below as clearly as possible what happened.

Explain below as clearly as possible what happened and why you believe you were discriminated against. Describe all persons involved. Include name and contact information of person (s) who discriminated against you (if known) as well as names and contact information of witnesses.

3. ADA Discrimination

Describe all persons who were involved. Include the name and contact information of the person(s) who discriminated against you (if known) as well as the names and contact information of any witnesses.
If this complaint is related to equipment or structures (for example: buses or bus stops), please try to be as specific as possible in identifying which vehicle or locations may be creating the situation.
Explain below as clearly as possible what happened and why you believe you were or are being discriminated against based on your disability.

Description

Section IV

Have you previously filed complaint with this agency?

Yes

What type of complaint did you file?

ADA

Title VI

Other

Section V

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

Yes

If yes, check all that apply and provide agency or court name

Federal Agency

State Agency

Local Agency

Federal Court

State Court

Federal Agency Name

State Agency Name

Local Agency Name

Federal Court Name

State Court Name

Section VI

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

Name

First Last

Title

Agency

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

You may attach any written materials or other information that you think is relevant to your complaint.

Drop files here or

Max. file size: 100 MB.

Signature

Date