VILLAGE OF ORLAND PARK GRIEVANCE FORM

Please fill out this form completely. Please note that this ADA notification

procedure is for facilities, services, and programs owned and/or operated

by the Village of Orland Park.

Name (complainant): *

Address: *

Contact Numbers:

	Please list your contact numbers.
Home:	Please list your contact numbers.
Work:	Please list your contact numbers.
Mobile:	Please list your contact numbers.

E-mail address: *

Reason for grievance/complaint, or why you feel you have been discriminated against. The complaint should be in writing and contain information about the alleged discrimination such as name, address, phone number of complainant and location, date, and description of the problem. Use a separate sheet if more space is needed. *

0/500 characters

State if you require an alternative for any written follow-up communications:

Signature: *

clear

Date: * +

Add an Attachment:

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This form shall be submitted to:
Khurshid Hoda, ADA Coordinator
14700 South Ravinia Avenue
Orland Park, IL 60462
Phone: (708) 403-6128
Email: khoda@orlandpark.org

If you have questions about this form, need an accommodation, or a different format, please
contact Khurshid Hoda, ADA Coordinator.

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