ADA Complaint Form – Town of Kernersville

If you are unable to complete this form, please contact our ADA coordinator directly.

ADA Coordinator
Angie Whitley
ada@toknc.com
336-992-0741

ADA Complaint

Fields marked with an * are required

ADA Disclaimer

Kernersville prides itself in being an accessible community. If you are unable to access town services due to a disability or other physical impairment, please read our ADA complaint procedure and fill out the form below.

Name *

Email *

Phone *

Address

City

Zip

Complaint *

Please indicate in writing, your concern or complaint and indicate the approximate time, date, and location of the occurrence.

Resolution *

What do you think would resolve the problem or complaint?

This is an ADA complaint *

By Submitting this form you confirm that this complaint relates to the Americans with Disabilities Act.

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