Name First Last PhoneAddress Street Address Address Line 2 City ZIP Code Does your complaint concern discrimination in the delivery of services or in other discriminatory actions by BMTA in its treatment of you or others? If so, please indicate below the base(s) on which you believe these discriminatory actions were taken and your reason why.Complaint TypeRace/EthnicityColorNational OriginExplainWhat is the most convenient time and place for us to contact you about this complaint?Which BMTA employee is accused of discrimination? What was done?What remedy are you seeking for the alleged discrimination?Please provide a complete description of the incident that happened.We cannot accept a complaint if it has not been signed. Please sign and date this complaint form below:Your NameYour NameYour NameYour NameDate
