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  1. 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
    Phone: (408) 868-1252

  2. Complainant
  3. Person Discriminated Against (if other than complainant)
  4. Department or person which you believe has discriminated (if known)
  5. Have efforts been made to resolve this complaint?
  6. 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?
  7. Do you intend to file with another agency or court?
  8. 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.

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  10. This field is not part of the form submission.