GREYSTONE POWER CORPORATION
LIMITED ENGLISH PROFICIENCY (LEP) COMPLAINT FORM
(EXHIBIT “A”)
(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 is mailed, please send to the following address:
GreyStone Power Corporation
Dept. Mgr. Human Resources (LEP Compliance Officer)
P.O. Box 897
Douglasville, GA 30133