Member Information

First Name *

Last Name *

Membership/License Number: *

Grievance Information

Alleged Grounds of Violation or Noncompliance: *

USAC Bylaw, Rule, Policy, Procedure or provision of the USOPC Bylaws or Ted Stevens Olympic and Amateur Sports Act alleged to have been violated: *

Remedy Requested: *

Supporting Documentation

Please attach up to fice (5) documents below in support of this Complaint.

Opportunity to Participate Matter Only

List of Individuals Who May Be Adversely Affected by the Outcome: *

Signature: *

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Date: * +

Street Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

Complaints received through this form will be sent directly to USA Cycling's CEO (or their designee) and the Board Chair.

Neither USAC nor any USAC member, employee, coach, official, officer, board member, or any other individual affiliated with USAC shall retaliate against an individual for filing a complaint or making a report under USAC’s Grievance Policy, or for participating in a proceeding under USAC’s Grievance Policy, in good faith. Additional prohibitions on retaliation and protection for whistleblowers are contained in USAC’s Whistleblower and Anti-Retaliation Policy, which can be found HERE.