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Grievance Form - Americans With Disabilities Act (ADA)

  1. Instructions:

    Please fill out this form completely. Alternative means of filing a grievance complaint, such as a personal interview or audio recording, will be made available upon request to the ADA Coordinator, whose contact information is listed at the end of this form.

  2. (if different from street address)

  3. Primary Phone Type*

  4. Secondary Phone Type

  5. Person Discriminated Against

    (if other than complainant)

  6. If different from street address

  7. Primary Phone Type

  8. Secondary Phone Type

  9. Has a complaint been filed with another bureau of the Department of Justice or any other federal, state, or local civil rights agency or court? *

  10. Do you intend to file with another agency or court? *

  11. Submits to:

    Charles G. Peller, Jr., Engineer/ADA Coordinator, 100 E. Michigan Boulevard, Michigan City, Indiana 46360, cpeller@emichigancity.com, (219) 873-1426 (ext. 333)

  12. 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.

  13. Leave This Blank:

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