Town of Davie Form Center

2. Town of Davie

   8800 SW 36th Street

   Davie, Florida 33328

   Phone: 954-797-1000

   Fax: 954-797-1087

4. Town of Davie
   Title VI and ADA Complaint of Discrimination
6. Complainant Name
7. Address
9. Phone Number
10. Email Address
12. Please List the Names, Addresses and Phone Numbers of Any Witnesses
14. Location of Incident
15. Date of Incident
    Date of Incident
17. Type of Discrimination

    1. Race
    2. Color
    3. Nation Origin
    4. Sex
    5. Age

    1. Handicap / Disability
    2. Income Status
    3. Retaliation
    4. Other
19. Please explain how, why, when and where you believe you were discriminated against. Include as much background information as possible about the alleged acts of discrimination.
21. 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.
23. Electronic Complainant Signature
24. Date of Signature
    Date of Signature
26. Note: Alternate means of filing complaint, such as a personal interviews or a tape recording of the complaint, will be made available for persons with disabilities upon request.
28. Submit to:

    Evelyn Roig, Town Clerk

    ADA Coordinator

    Town of Davie

    8800 SW 36th Street

    Davie, Florida 33328

    Email: Evelyn_roig@davie-fl.gov

    Phone: 954-797-1000

    Fax: 954-797-1087

    TTY: 954-828-5520

    Florida Relay (Voice): 800-955-8770

    Florida Relay (TTY): 800-955-8771

Leave This Blank:


30. Submit

* indicates a required field