MITS is committed to ensuring that no person shall on the grounds of race, color, or national origin, as provided by Title VI, be excluded from participation in, be denied the benefits of, or otherwise subjected to discrimination under any program or activity receiving Federal financial assistance.
The following information is necessary to assist us in processing your complaint. You may print this form and complete it. If you require any assistance in completing this form, please contact the Director of Finance and Human Resources, MITS. 1300 E Seymour St, Muncie IN 47302, 765-282-2762.
Your Name Street Address City, State, Zip Phone Number Alternate Phone Number Email Address Person(s) discriminated against (if someone other than complainant) Street Address City, State, Zip
Which of the following best describes the reason for the alleged discrimination that took place? Race Color National Origin/Limited English Proficiency
Date of Incident
Please describe the alleged discrimination incident. Provide the names and title of all MITS employees involved if available. Explain what happened and who you believe was responsible. Please attach additional pages if additional space is required.
Have you filed a complaint with any other federal, state or local agencies? Yes No If yes, list agency(s) and contact information below: Agency Agency Contact Name Street Address City, State, Zip Phone Number
I affirm that I have read the above charge and that it is true to the best of my knowledge, information, and belief. Complainant's Signature _____________________________________________________________
Printed Name of Complainant Date
Print and return your completed form to: MITS Director of Finance & Human Resources 1300 E Seymour St Muncie IN 47302
