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TITLE VI • FORM <br />The County of Hawai'i Mass Transit Agency (MTA), as a recipient of Federal Funds, will <br />fully comply with Title VI of the Civil Rights Act of 1964. MTA is committed to ensuring <br />that no person using the Hele On Bus, paratransif service or its shared ride taxi program <br />is discriminated against on the basis of race, color or national origin. <br />Please provide the folloing information necessary in order to process your complaint. <br />Assistance if available upon request by calling 808-961-8744. Complete this form and <br />mail to County of Hawaii, Mass Transit Agency, 25 Aupuni Street or deliver to: 2299 <br />Ho'olaulima Road, Hilo, HI 96720, <br />Section I <br />Complainant's Name: <br />Address: <br />City: State: <br />Email Address: <br />Telephone No. (Home): <br />Section 11 <br />(Business): <br />Zip Code: <br />Are you filing this complain on your own behalf? ( ) Yes* <br />*If you answered "yes" to this questions, go to Section 111. <br />If not, please supply your Information here: <br />Name: <br />Address: <br />City: <br />Email Address: <br />State: <br />Zip Code: <br />Relationship to the person for whom you are complaining: <br />Please explain why you have filed for a third party: <br />Please confirm that you have obtained the permission of the aggrieved party if you are <br />filing on behalf of a third party. ( ) Yes ( ) No <br />