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2. ADA Complaint Policy
   Read the ADA Complaint Policy (PDF)
4. Complainant*
5. Date of Incident*
   Date of Incident
7. Address*
9. City*
10. State*
11. Zip Code*
13. Phone Number*
15. Person Preparing Complaint if different from Complainant
17. Address
19. City
20. State
21. Zip Code
23. Please describe the alleged discriminatory incident, including the locations, if applicable. Provide the names and titled of Fort Lee Parking Authority employees involved, if available.*
25. Have you filed a complaint with any other federal, state, or local agencies?*

    1. Yes
    2. No
27. Agency Name
28. Phone Number
30. Address
32. City
33. State
34. Zip Code
36. 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.
38. Electronic Signature*
39. Date*
    Date
44. 
Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field