Title IX - Arizona Western College

Human Resources
P.O. Box 929, Yuma, Arizona 85366-0929
Phone: 928-344-7504 or 1-888-293-0392 TTY: 928-726-0329
FAX: 928-317-6001
www.azwestern.edu
Title IX Grievance Form
The information you provide will be treated in a confidential manner.
Arizona Western College is an equal opportunity employer and affords equal opportunity to all applicants for all positions.
Arizona Western College es un empleador con igualdad de oportunidades y extiende esta igualdad de oportunidades a todos los solicitantes para
todas las vacantes.
Name
(Please Print)
(last)
(first)
(middle)
Home Telephone:
Work Telephone:
Mailing
Address
Alternate Telephone:
City
State
Mark One:
Student
Employee
Zip
Parent
E-Mail:
Other [on behalf of Student/Employee]
Specifics of complaint (describe below, including any dates of alleged discrimination).
Attach an extra page if necessary.
List any witnesses to alleged Title IX violation (include names and contact information if known).
Attach an extra page if necessary.
Indicate what, if any corrective action you would like occur with regard to the possible Title IX violation.
Attach an extra page if necessary.
________________________________________
Signature of Complainant
___/___/___
Date
Please return completed form to :
Dr. L. Ruth Whisler, Title IX Compliance Officer
Office: 2A21 located in 3C Building-Mezzanine Floor
Yuma, AZ 85366
Revised: 3/13