Title VI Non-Discrimination

2. This form may be used to file a complaint with the City of Mission based on violations of Title VI of the Civil Rights Act of 1964. Complaints should be filed within 180 days of the alleged discrimination. If you could not reasonably be expected to know the act was discriminatory within 180 day, you have 60 days after you become aware to file a complaint. Return the signed form to the City of Mission, Purchasing Department, 1201 E 8th Street, Mission, Texas 78572.

4. First Name*
5. Last Name*
7. Mailing Address*
9. City
10. State
12. Zip Code
13. Country
15. Phone Number*
16. Alternate Phone
18. Email Address
20. Please indicate the basis of your complaint:*

    1. Race
    2. Age
    3. Color
    4. Gender
    5. National Origin
    6. Disability
    7. Income
22. Date(s) and place(s) alleged discriminatory action took place, including earliest date of discrimination and most recent date of discrimination:*
24. Name(s) of City Department, programs, and individuals responsible for discriminatory action(s):*
26. Please explain as clearly as possible how you were discriminated against. Describe the nature of the action, decision, or conditions of the alleged discrimination. Include how you were treated differently from others based on your protected status.*
28. Names of persons (witnesses, other subjected to discrimination, fellow employees, supervisors, or others) whom we may contact for additional information or to clarify your complaint:
30. Name
31. Phone
32. Email Address
34. Name
35. Phone:
36. Email Address
38. Name
39. Phone
40. Email Address
42. Name
43. Phone
44. Email Address
Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field