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2. Please complete this form to request accommodations or to file a complaint with the City of Everett coordinator. Only fields with an asterisk (*) are required. All other fields are optional.

   This form is for public use only. City of Everett employees seeking accommodations should contact Human Resources.

4. First name*
5. Last name*
7. Address*
9. City*
10. State*
11. Zip code*
13. Email address
14. Phone number*
16. What is your preferred mode of contact?*

    1. Email

    1. Phone

    1. Postal mail
18. I want to:*
    -- Select One --request accommodationsfile a complaint

    Please select from the drop down menu

20. What kind of accommodation are you requesting?*

    Please tell us the type of accommodations you need. If it's an event, please include the date of the event. If it's a location, please tell us the address of the location. 

22. Please describe the incident prompting this complaint*
24. Where did the incident occur?
25. When did the incident occur?*
    When did the incident occur?
27. I was discriminated against because of:

    1. Race/color
    2. National origin
    3. Creed/religion
    4. Disability

    1. Sex (includes sexual harassment)
    2. Sexual orientation
    3. Marital status
    4. Age

    1. Vietnam Era Veteran
    2. Disabled Veteran
    3. Retaliation
29. The City of Everett aims to help you resolve your issue(s). Please note that this process will not result in the payment of punitive damages or financial compensation.
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field