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Request for Accommodation Procedure Under the Americans with Disabilites Act
Discrimination Comment, Concern or Complaint Form
This Request for Accommodation Procedure is established to meet the requirements of the Americans with Disabilities Act (ADA). It may be used by anyone who wishes to file a complaint alleging discrimination on the basis of disability in the provision of services, activities, programs, or benefits by the City of Republic, Missouri. The ADA prohibits discrimination against any qualified individual with a disability and provides protections to individuals with disabilities that are at least equal to those provided by the nondiscrimination provisions of Title V of the Rehabilitation Act of 1973. Title V includes Section 504, which covers all public entities including local government and any of its departments, agencies, meetings or other instrumentalities. Title II may not be interpreted to provide a lesser degree of protection to individuals with disabilities than is provided under these laws. Anonymous complaints or grievances will not be accepted. Complaints or grievances will be kept confidential to the greatest extent possible, unless ordered released by a court of competent jurisdiction.
Grievant Name:*
Address*
Address Line 2
City*
State*
Zip Code*
Home Telephone*
Business Telephone
Was the person who was discriminated against someone other than the grievant?*
1. Yes
1. No
Person Discriminated Against (if other than the grievant):*
Address*
Address Line 2
City*
State*
Zip Code*
Home Telephone*
Business Telephone
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Business or Organization Information

Government, or organization, or institution which you believe has discriminated:
Business or Organization Name*
Address
Address Line 2
County
City
State
Zip Code
Telephone Number
When did the discrimination occur?*
When did the discrimination occur?
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Details of Incident

Describe the acts of discrimination providing the name(s) where possible of the individual(s) who discriminated*
Have any other efforts been made to resolve this complaint through the internal grievance procedure of the City of Republic?*
1. Yes
1. No
If yes, what is the status of the grievance?*
Has the complaint been filed with the Department of Justice or any other Federal, State, or local civil rights agency or court?*
1. Yes
1. No
If yes, which Agency or Court?*
Agency or Court Contact Person
Address
Address Line 2
City
State
Zip Code
Telephone Number
Date Filed*
Date Filed
Do you intend to file with another agency or court?*
1. Yes
1. No
If yes, which Agency or Court?
Address
Address Line 2
City
State
Zip Code
Phone Number
Electronic Signature Agreement*
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature*
This form may be submitted electronically or printed and mailed, faxed, emailed, or hand delivered to: City of Republic, ADA Coordinator, 204 N Main, Republic, MO 65738; Phone: (417) 732-3165; Fax: (417) 732-3199; Email: adacompliance@republicmo.com This form is covered by the Privacy Act of 1974. Public Law 93-597.

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