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Complaint Form

Personal Information
First Name
Middle Initial
Last Name
Street Address
Apt. / Ste #
City
State
Zip
Phone
Email Address
Where it happened. i.e., Name of Business, Address, Street Name etc.
Location of incident
City
State
Zip
Date of incident
Time of incident
Complaint
By submitting this form you agree to the following statement: I agree that the above complaint is true and factual. I authorize Disabilities Rights Advocacy Group Inc.,(D.R.A.G.) to act on my behalf, and to attempt to resolve this complaint.
  

Disabilities Rights Advocacy Group, Inc.
Phone/Fax:(215)477-4956
Email: bruce.mcelrath@draginc.com
www.draginc.com

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