Virgin Islands Port Authority Title VI Complaint Form  
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Virgin Islands Port Authority 
 Gateways to the USVI’s Economy 
VIRGIN ISLANDS PORT AUTHORITY 
TITLE VI COMPLAINT FORM 
Name of Complainant: 
Sex: 
Race /Ethnic Group: 
Mailing Address: 
City:   
 Zip: 
Home Telephone: 
Cell Phone: 
Work Telephone: 
Email Address: 
 Accessible Format  
⃞ Large Print 
 ⃞ Audio Tape 
⃞ TDD 
    Preferred:  
     ⃞ Other 
SECTION II 
Are you filling this complaint on your own behalf?     ⃞ Yes   
 ⃞No   [If you answered “yes” to this question, go to Section IV.] 
If not, please supply the name and relationship of the person for whom you are complaining: 
Please explain why you have filed for a third party: 
Please confirm that you have obtained the permission of the aggrieved party if you are filing on: 
⃞ Yes 
 ⃞ No 
SECTION III 
What was the reason you believe you were discriminated against?   
⃞ Race   
⃞ Color  
⃞ National Origin 
Date of Alleged  Discrimination:   (Month,  Day, Year) 
What is the name and address of the institution, agency or person that you believe discriminated against you?: Name: 
Mailing Address: 
City:   
 Zip: 
 Phone #: 
Describe how you were discriminated against. What happened and who was responsible?  Please be as specific as possible. Attach 
additional page (s) if necessary 
Please List Name of persons, witnesses, fellow employees, supervisors, or others whom we may contact for additional information, support 
or clarification of your complaint: 
1. Name:
 Phone No: 
2. Name:
 Phone No: 
3. Name:
 Phone No: 
Virgin Islands Port Authority Title VI Complaint Form  
Page 2 of 2 
Virgin Islands Port Authority 
 Gateways to the USVI’s Economy 
What type of corrective action would you like to see taken? 
SECTION IV
Did you file this complaint with another Federal or local agency; or with a Federal or local court?      ⃞Yes 
 ⃞No 
If answer is yes, check each agency complaint was filed: 
Federal Agency                      ⃞ Federal Court                   ⃞ Local Court                   ⃞ Local Agency 
Date filed 
Please provide contact person information for the agency or court where the complaint was filed: 
Name: 
Telephone: 
Address:  
 City:   
 Zip: 
Please sign and date this complaint form below.  
 Attach any supporting document(s) you think is relevant to your compl aint. 
Signature: 
 Date: 
This form can be submitted in person, mail, or email 
to: 
Daphne Durand Mayers
Legal & Programs Management Officer 
8074 Lindbergh Bay 
St. Thomas, VI 00802 
Phone:  340.714.6402
Email:   dmayers@viport.com