MyACCESSRide.com
TITLE VI COMPLAINT FORM| Revised 10/19
Title VI Complaint Form
If you feel you've been discriminated against, please print this form to submit
your complaint to:
Customer Service Department
ACCESS Transportation Systems
650 Smithfield Street, 4th Floor
Pittsburgh, PA 15222-2527
Section I: Personal Information
*First Name: ___________________________________________________________
*Last Name: ___________________________________________________________
*Address1: ____________________________________________________________
Address2: ____________________________________________________________
*City: _____________________________*State: _______*Zip: __________
Telephone (Home): ____________________Telephone (Cell): __________________
Email: ________________________________________________________________