ADA GRIEVANCE FORM

The Town of Pembroke, in accordance with the Americans with Disabilities Act (ADA), may not discriminate against persons with disabilities to access and participate in its programs, services, activities and employment. Anyone who wishes to file a complaint alleging disability discrimination concerning services, programs, employment practices, etc. may do so electronically by filling out the information below or by printing out this form and submitting it to: Board of Selectmen's Office, Attn: ADA Coordinator, 100 Center Street, Pembroke, MA 02359. Submissions can also be handled in person at the Town Hall Room 10.

Filing Date: *

Month

Day

Year

Date of Alleged Incident: *

Month

Day

Year

First Name: *

Last Name: *

Street Number: *

Street Name: *

City: *

State: *

Zip: *

Telephone: *

E-mail *

The alleged act of discrimination involves which Town department, meeting, agency or program? *

Describe the alleged act of discrimination: *

Attach Photos & Files:

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png.

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