AC-E ©

EXHIBIT

NONDISCRIMINATION / EQUAL  OPPORTUNITY

COMPLAINT FORM -
DISCRIMINATION, HARASSMENT, OR RETALIATION
(To be filed with the compliance officer as provided in AC-R)

Please print:

Name _________________________________     Date ________________

Address ______________________________________________________

Telephone ________  Another phone where you can be reached _________

During the hours of _____________________________________________

E-mail address  ________________________________________________

I wish to complain against:

Name of person, school (department), program, or activity  ______________

_____________________________________________________________

_____________________________________________________________

Address ______________________________________________________

Specify your complaint by stating the problem as you see it.  Describe the incident, the participants, the background to the incident, and any attempts you have made to solve the problem.  Be sure to note relevant dates, times, and places.

_____________________________________________________________

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_____________________________________________________________

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_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

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If there is anyone who could provide more information regarding this, please list name(s), address(es), and telephone number(s).

Name                                  Address                                  Telephone Number

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

The projected solution

Indicate what you think can and should be done to solve the problem.  Be as specific as possible.

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

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I certify that this information is correct to the best of my knowledge.

____________________________________
Signature of Complainant

The compliance officer, as designated in AC-R, shall give one (1) copy to the complainant and shall retain one (1) copy for the file.