"Americans With Disabilities Act (Ada) Complaint Form" - Florida

Americans With Disabilities Act (Ada) Complaint Form is a legal document that was released by the Florida Department of Business & Professional Regulation - a government authority operating within Florida.

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  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Florida Department of Business & Professional Regulation.

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AMERICANS WITH DISABILITIES ACT (ADA)
Complaint Form
This form may be used by any individual to file a complaint alleging discrimination on the basis
of disability in meetings, services or activities of the Florida Department of Business and
Professional Regulation (DBPR) under Title II of the ADA. Alternate means of filing a complaint,
such as personal interviews or tape recordings, are available upon request for people with
disabilities. All complaints will be kept on file for a minimum of three years.
Filing Date: _____________________ Date of Alleged Incident: _______________________
Complainant Name: ___________________________________________________________
Home Address: _______________________________________________________________
Phone#: ________________________ Email: _______________________________________
The alleged act of discrimination involves which DBPR Division, meeting, agency or program?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Describe the alleged act of discrimination (additional paper may be attached):
This complaint form (or alternate reporting method) should be submitted by the complainant or
his/her designee as soon as possible, but no later than 120 days after the alleged violation, to:
Kimberly Allen
Kimberly.Allen@myfloridalicense.com
Florida Department of Business & Professional Regulation
2601 Blair Stone Road Tallahassee, FL 32399-1010
850.717.1754 (phone) 850.921.8992 (fax)
AMERICANS WITH DISABILITIES ACT (ADA)
Complaint Form
This form may be used by any individual to file a complaint alleging discrimination on the basis
of disability in meetings, services or activities of the Florida Department of Business and
Professional Regulation (DBPR) under Title II of the ADA. Alternate means of filing a complaint,
such as personal interviews or tape recordings, are available upon request for people with
disabilities. All complaints will be kept on file for a minimum of three years.
Filing Date: _____________________ Date of Alleged Incident: _______________________
Complainant Name: ___________________________________________________________
Home Address: _______________________________________________________________
Phone#: ________________________ Email: _______________________________________
The alleged act of discrimination involves which DBPR Division, meeting, agency or program?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Describe the alleged act of discrimination (additional paper may be attached):
This complaint form (or alternate reporting method) should be submitted by the complainant or
his/her designee as soon as possible, but no later than 120 days after the alleged violation, to:
Kimberly Allen
Kimberly.Allen@myfloridalicense.com
Florida Department of Business & Professional Regulation
2601 Blair Stone Road Tallahassee, FL 32399-1010
850.717.1754 (phone) 850.921.8992 (fax)