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Americans with Disabilities Act Complaint Form

  1. Americans with Disabilities Act Complaint Form

    5 Town Dial-a-Ride is committed to ensuring that no person is denied access to its services, programs, or activities on the basis of their disabilities, as provided by title II of the Americans with Disabilities Act of 1990 (“ADA”). ADA complaints must be filed within 180 days from the date of the alleged incident.

    The following information is necessary to assist us in processing your complaint. If you require any assistance in completing this form, or if you would like to make a verbal complaint, please contact the “enter Contact information”.

  2. Have you filed a complaint with any other federal, state, or local agencies?

  3. Electronic Signature*

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