Request for ADA Grievance Resolution

Today's Date*
Date of Complaint*
Date Format: MM slash DD slash YYYY
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

Accepted file types: jpg, pdf.
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.*
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