Butler County Sheltered Workshop

Manufacturers Assistance Group Title VI Complaint Form

"No person in the United States shall, on the grounds of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance."

If you feel that you have been discriminated against in the provision of transportation services, please provide the following information to assist us in processing your complaint. Should you require any assistance in completing this form or need information in alternate formats, please let us know.

Please mail or return this form to:

JEFF ARNOLD

MANUFACTURERS ASSISTANCE GROUP

3080 CRAVENS ROAD

POPLAR BLUFF MO, 63901

jmamag@mycitycable.com fax#: 573-712-2512

Please click Print below to download the printer friendly version of the form if you are not completing the on-line version of this form.

(PDF format)

Large Print
Audio Tape
TDD
Other
Yes
No
Yes
No
Yes
No
Race
Color
National Origin (classes protected by Title VI)
Other
Yes, I have permission
No, I do not have permission
Federal Agency
Federal Court
State Court
State Agency
County Court
Local Agency