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2. Instructions

   Please fill out this form completely. If you need an accommodation to complete or submit this form, please contact the ADA/504 Coordinator:

   Monica LaBossiere, ADA/504 Coordinator
   City of Saratoga
   13777 Fruitvale Avenue
   Saratoga, CA 95070
   Email: mlabossiere@saratoga.ca.us
   Phone: (408) 868-1252

4. Complainant
6. First Name*
7. Last Name
9. Address
11. City
12. State
13. Zip Code
15. Phone Number*
16. Email Address
18. Person Discriminated Against (if other than complainant)
20. First Name
21. Last Name
23. Address
25. City
26. State
27. Zip Code
29. Phone Number
30. Email Address
32. Department or person which you believe has discriminated (if known)
34. First Name
35. Last Name
37. Address
39. City
40. State
41. Zip Code
43. Phone Number
44. Email Address
46. Date Discrimination Occurred
    Date Discrimination Occurred
48. Describe the act(s) of discrimination, including the name(s) of the individuals who discriminated, if possible:
50. Have efforts been made to resolve this complaint?

    1. Yes
    2. No
52. What efforts have been taken, and what is the status of the grievance?
54. Has the complaint been filed with another bureau, such as the Department of Justice or any other Federal, State, or local civil rights agency or court?

    1. Yes
    2. No
56. Agency or Court
57. Contact Person
59. Address
61. City
62. State
63. Zip Code
65. Phone Number
66. Date Filed
    Date Filed
68. Do you intend to file with another agency or court?

    1. Yes
    2. No
70. Agency or Court
72. Address
74. City
75. State
76. Zip Code
78. Phone Number
80. Additional Comments or Information:
82. 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.
84. Electronic Signature*
85. Date*
    Date
Leave This Blank:


87. 1. Receive an email copy of this form.
88. Email address

    This field is not part of the form submission.

89. Submit

* indicates a required field