DOT Form 1050-9 DESIGNATION OF REPRESENTATIVE FORM

OMB No: 2105-0556

Expiration Date: MM/DD/YYYY

Public Burden Statement

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number.  The OMB Control Number for this information collection is 2105-0556.  Public reporting for this collection of information is estimated to be approximately 2.5 hours per respondent, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information.  All responses to this collection of information are voluntary.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, U.S. Department of Transportation, Room W56-440, 1200 New Jersey Ave, SE, Washington, D.C. 20590.

Date: ___________________________________________

Subject: DESIGNATION OF REPRESENTATIVE FORM

From: ___________________________________________

Aggrieved Individual

To: Office of Civil Rights

The person or firm listed below has been designated as my representative regarding my equal employment opportunity claim(s) of discrimination:

NAME: ______________________________________________

ADDRESS: ­­­­­­­­­­­­­­­ ______________________________________________

______________________________________________

______________________________________________

TELEPHONE NUMBER: _______________________________________________

E-MAIL: ___________________________________________________

FAX NUMBER: ___________________________________________________

Attorney Status: (select one) Yes No

________________________________________________________

(Aggrieved Individual’s Signature)

PRIVACY ACT STATEMENT

1. FORM NUMBER/TITLE DATE: U.S. Department of Transportation (DOT) Form Number DOT F 1050-9, Designation of Representative, March 1, 2006.

2. AUTHORITY: 42 U.S.C. § 2000e-16(b) and (c); 29 U.S.C. §§ 204(f) and 206(d); 29 U.S.C. § 633(a); 29 U.S.C. § 791; Reorg. Plan No. 1 of 1978, 43 FR 19607 (May 9, 1978); Executive Order No. 12106, 44 FR 1053 (January 3, 1979).

3. PRINCIPAL PURPOSES: These records are maintained for the purpose of counseling, investigating and adjudicating complaints of employment discrimination brought by applicants and current and former Federal employees against Federal employers. This particular form allows an aggrieved individual or formal Equal Employment Opportunity (EEO) complainant to designate an individual to represent him/her during the processing of an EEO complaint.

4. ROUTINE USES: The routine use is to refer pertinent information to the appropriate Federal, State, or local agency responsible for investigating, prosecuting, enforcing, or implementing a statute, rule, regulation, or order where there is an indication of a violation or potential violation of civil or criminal law or regulation.

5. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY, AND EFFECT ON INDIVIDUAL BY NOT PROVIDING INFORMATION: The designation of a representative is solely voluntary by an aggrieved individual or formal EEO complainant. Failure to designate a representative will not preclude the representation of the aggrieved individual or EEO formal complainant by any other person during the processing of the EEO complaint.