LEP Complaint Form

LEP Complaint Form

GREYSTONE POWER CORPORATION

LIMITED ENGLISH PROFICIENCY (LEP) COMPLAINT FORM

(EXHIBIT “H”)

 

(Internal Use)

Date Received: ____/______/__________

Method Received: _____/_____/________

Verbal Complaint?      Y         N

Name of Employee Completing Form on Behalf of Complainant:

 

___________________________________

 

Contact Information:

 

Name _________________________________________

 

Address _______________________________________

 

City ____________________________   State _________

 

Zip _______________

 

Telephone _________________________

 

Email __________________________________________

 

Complaint:

Facts and circumstances surrounding the complaint, including the date of the allegation, and the legal basis of the complaint (i.e., race, color, national origin, or LEP status):

_____________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

   Any names of persons, if known, whom the Cooperative could contact for additional information to support or clarify the allegations, and contact information for those persons:

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Corrective action or remedy requested:

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Sign the complaint in the space below. Attach any documents that support your complaint.


Complainant’s Signature___________________________________   Date___________________________

If the form mailed, please send to the following address:

GreyStone Power Corporation

LEP Compliance Officer

P.O. Box 897

Douglasville, GA 30133

 

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