ADA Coordinator
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Borough of Lavallette
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1306 Grand Central Avenue
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Lavallette, NJ 08735
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Americans with Disabilities Act Grievance Form
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Date:
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Name of grievant:
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Address of grievant:
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Telephone number of grievant:
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Name, address and telephone number of alternate contact person:
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Department alleged to have denied access:
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Please describe the particular way in which you believe you have been
denied the benefits of any service, program or activity or have otherwise
been subject to discrimination. Please specify dates, times and places of
incidents, and names and/or positions of employees or other persons involved,
if any, as well as names, addresses and telephone numbers of any witnesses
to any such incident. Attach additional pages necessary.
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Proposed access or accommodation:
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If you wish, describe the way in which you feel access may be had to
the benefits described above, or that accommodation could be provided to allow
access.
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