Request for ADA Grievance Resolution

Today's Date*

Date of Complaint*

Name of Individual (Grievant)*

Location of Complaint*

Names of Parties Involved*

Nature of Complaint Detailing Specific Events*

You may attach digital versions of any documentation that may support your grievance below.

Prior Attempts To Resolve*

Please indicate any previous efforts to resolve your complaint including dates and parties involved.

Documentation Upload

Drop files here or

If you have any documentation that may support your grievance, please upload here.

.JPG and .PDF files are accepted, up to 15 MB in size. If you have more documentation and/or do not have digital copies, you may bring it to:

George DeCroes, ADA Coordinator
City of Kingsport
301 Louis Street, Suite 303
Kingsport, TN 37660

Print Name*

First Last

Your Email

If you provide an email address, a .pdf copy of this request will be emailed to you.

Your Phone*

Signature*

By checking this box and submitting this form, I certify all info is true and correct to my knowledge.*

Yes

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.