Title VI Complaint Form

England Economic and Industrial Development District (England Authority)

Alexandria International Airport (AEX)

Please complete this form if you believe Alexandria International Airport, its airport operators, lessees, tenants, concessionaires, or contractors have discriminated against you based on race, color, national origin, age, sex, or creed in airport services, programs, opportunities, or activities.

If you are a Limited English Proficient (LEP) individual and believe Alexandria International Airport did not provide adequate language assistance regarding a service, benefit, or encounter, please also complete this form.

Submit this webform electronically below, or email your completed form to DKeller@englandairpark.org. You may also mail it to:

England Economic and Industrial Development District
Attn: David Keller, Airport Manager
1611 Arnold Drive
Alexandria, LA 71303

Section I

Name(Required)

First Last

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Telephone (home)(Required)

Telephone (work)

E-Mail(Required)

Section II

Are you filing this complaint on your own behalf?(Required)

Yes

If you answered “Yes” to this question, go to Section III.

If no, please supply the name of the person for whom you are complaining

Relationship to the person for whom you are complaining

Please explain why you have filed for a third party

Please confirm that you have obtained the permission of the aggrieved third party

Yes

Section III

I believe the discrimination I experienced was based on (check all that apply)(Required)

If other, please specify

Date of Alleged Discrimination(Required)

Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons who were involved.(Required)

Include the name(s) and contact information of the person(s) who discriminated against you (if known)

Please list any and all witnesses’ names, employers, and contact information, if applicable

What type of corrective action would you like to see taken?

Section IV

Have you previously filed a Title VI complaint with Alexandria International Airport (AEX)?(Required)

Yes

Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court?(Required)

Yes

If yes, please check all that apply

Federal Agency

State Agency

Federal Court

Local Agency

State Court

Name

Title

Agency

Telephone

Address

Please, provide information about a contact person at the agency/court where complaint was filed.

Contact person name at the agency/court where complaint was filed

Contact person title

Agency/Court

Agency/Court Telephone

Agency/Court Address

Street Address City State / Province / Region ZIP / Postal Code

Section V

Please list any person(s) whom we may contact for additional information to support your complaint. Attach additional sheets, if necessary.

Contact information

Name

Telephone

Address

Section VI

Do you have any other information that you think is relevant to the investigation of your complaint? Attach additional sheets, if necessary.

Upload any written materials or other information relevant to your complaint

Drop files here or

Accepted file types: pdf, doc, docx, jpg, jpeg, png, Max. file size: 512 MB, Max. files: 10.

Signature (typed name)(Required)

First Last

Date(Required)