Complete this form if you believe you have been discriminated against on the basis of race, color, national origin, disability, sex, or age by any representative of RVARC, its programs, or its consultants. You can obtain a paper copy of this form at 313 Luck Ave SW or by mail upon request.

Question Title

* 1. Name

Question Title

* 2. Address

Question Title

* 3. Telephone

Question Title

* 4. Email

Question Title

* 5. Are you filing this complaint on your own behalf?

T