Email Complaint Form – The Green Mountain Express

Green Mountain Community Network, Inc. receives federal grants to provide various modes of transportation in Bennington County. GMCN has processes in place to receive, investigate, and track complaints. ADA complaints are process as required by 49 CFR 27.121(b). GMCN keeps all ADA complaints in its active file for twelve months and in summary form for five years.

Title VI complaints are processes as required by 49 CFR 21.9b. GMCN keeps all Title VI complaints in its active files for twelve months and in summary form for five years.

Online Civil Rights Complaint Form

Complaint Type

This is an ADA Complaint
This is a Title VI Complaint

Section I - Basis of Complaint

I believe that I have been (or someone else has been) discriminated against on the basis of:

Race/Color/National Origin
Sex/Gender
Age
Disability
Retaliation
Other (specify in the box below)

Other (copy)

I believe that a public transit provider has failed to comply with the following program requirements:

Disadvantaged Business Enterprise
External Equal Employment Opportunity
Not applicable
Other (specify in the box below)

Other

Section II - Your Details

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Section III - Who discriminated against you?

Offender's Name

Name of Organization

Address of Organization

Address Line 1

City

State

Zip Code

How were you discriminated against?

Where did the discrimination occur?

Dates and times discrimination occurred?

Were there any other witnesses to the discrimination? (Name, Organization/Title, Contact Information)

How would you like to see this situation resolved?

Have you filed your complaint, grievance, or lawsuit with any other agency or court?

Who?

When?

Status (pending, resolved, etc.)

Result, if known

Complaint number, if known

Do you have an attorney in this matter?

Attorney Name

Phone

Attorney's Address

Address Line 1

City

State

Zip Code

By submitting this form I certify this statement is true to the best of my knowledge.