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Request For Review of Decision of Ada Coordinator - Americans With Disabilities Act (ADA)

  1. Instructions:
    Please fill out this form completely. Alternative means of filing a grievance complaint, such as a personal interview or audio recording, will be made available upon request to the Clerk’s Office, whose contact information is listed at the end of this form.
  2. (if different from street address)
  3. Primary Phone Type*
  4. Secondary Phone Type
  5. Submits to:
    Michigan City Clerk’s Office, 100 E. Michigan Boulevard, Michigan City, Indiana 46360, Attn: Gale Neulieb,, (219) 873-1410 (telephone)
  6. Electronic Signature Agreement
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
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  8. This field is not part of the form submission.