E-Gov Services Village of Romeoville

Americans with Disabilities (ADA) Act Complaint Form

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Purpose. The Village of Romeoville 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 the Americans with Disabilities Act. 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 Eric Bjork 815-886-1870.

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Contact Information

First Name:
Last Name:
Email:
Daytime Phone:	() –
Address:
City:
State:
ZIP:

Person Preparing Complaint (If different from Complainant)

Date of Incident

Please describe the alleged discriminatory incident or location. Provide as much as detail as possible.

Have you filed a complaint with any other federal, state or local agencies? If yes list the agency/agencies and contact information below

Yes

If you have filed a complaint with another agency for this incident please provide information the agency name, contact name and number

Attach a Picture or File (max size: 30MB):

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Notes:

If you send us a message, you will receive a Tracking Number allowing you to follow-up with your request, at your convenience.

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