2. 
4. CITY OF DAPHNE ADA COMPLAINT/GRIEVANCE FORM

6. By request, reasonable accommodation will be provided in completing this form, or copies of the form will be provided in alternative formats. Contact the ADA Coordinator  by calling 251-620-2100 or by emailing weringman@daphneal.com.

8. NAME OF COMPLAINANT*
10. If someone other than the complainant is completing this form, please state relationship:
12. STREET ADDRESS OF COMPLAINANT*
14. CITY*
15. STATE*
16. ZIP CODE*
18. CONTACT PHONE*
19. CONTACT EMAIL ADDRESS*
23. STREET ADDRESS/LOCATION OF THE COMPLAINT*

    Please be as specific as possible as to the location.

25. PLEASE DESCRIBE THE COMPLAINT*
27. PLEASE DESCRIBE WHAT YOU BELIEVE MAY BE DONE TO RESOLVE THE COMPLAINT*
31. DIGITAL SIGNATURE OF COMPLAINANT*
32. DATE OF SUBMISSION*
    DATE OF SUBMISSION
Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field