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E and Zip Code: Home Phone: Business Phone: 2. Person Discriminated Against: (if other than the complainant) Address: City, State, and Zip Code: Home Phone: Business Phone: 3. Government, or organization, or institution which you believe has discriminated: Name: Address: City, State and Zip Code: Telephone Number: pg. 1 2012 NDOT ADA Complaint Form When did the discrimination occur? Date: Describe the acts of discrimination providing the name(s) where possible of the individuals who dis.

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