3. 
5. Title VI Complaint Form
   Title VI of the Civil Rights Act of 1964 requires TRPC programs to ensure protection from discrimination on the basis of race, color and national origin. This form may be used by anyone who believes he or she has experienced discrimination.
7. Questions
   If you have questions or need assistance, contact the TRPC Title VI Coordinator at 360-956-7575.
9. Section I
11. First Name
12. Last Name
14. Address1
16. Address2
18. City
19. State
20. Zip
22. Home Phone Number
23. Cell Phone Number
25. Email Address
29. Section II
31. Are you filing this complaint on your own behalf?

    1. Yes

    1. No

    If you answered Yes to this question, proceed to Section III.
33. If you answered No to the above question, please supply the name and relationship of the person for whom you are filing this complaint.
35. Please explain why you have filed for a 3rd party.
37. Please confirm you have obtained permission from the aggrieved party.

    1. Yes

    1. No
41. Section III
43. I believe the discrimination I experienced was based on:

    Select all that apply.

    1. Race

    1. Color

    1. National Origin
45. Date of alleged discrimination*
    Date of alleged discrimination
47. Explain what happened and why you believe you were discriminated against. Describe all persons who were involved. Include the name and contact information of the person(s) who discriminated against you (if known), as well as names and contact information of any witnesses. You may attach any written materials or other information relevant to your complaint.
51. Section IV
53. Have you previously filed a Title VI complaint with this agency?

    1. Yes

    1. No
55. Signature

    By checking this box, I authorize my signature.

    1. Signature
56. Date of Signature
    Date of Signature

    Date of Signature
Leave This Blank:


58. 1. Receive an email copy of this form.
59. Email address

    This field is not part of the form submission.

60. Submit

* indicates a required field