103.E4 - Discrimination Complaint Form

 

Date of complaint:	_____________________________________________________
Name of Complainant:	_____________________________________________________
Are you filling out this form for yourself or someone else (please identify the individual if you are submitting on behalf of someone else):	_____________________________________________________ _____________________________________________________
Who or what entity do you believe discriminated against you (or someone else)?	_____________________________________________________
Date and place of alleged incident(s):	_____________________________________________________ _____________________________________________________ _____________________________________________________
Names of any witnesses (if any):	_____________________________________________________

 

Nature of discrimination alleged (check all that apply):

	Age		Religion
	Disability		Creed
	Gender Identity		Sex
	Marital Status		Sexual Orientation
	National Origin		Socioeconomic Status
	Race/Color		Other – Please Specify

 

In the space below, please describe what happened and why you believe that you or someone else has been discriminated against. Please be as specific as possible and attach additional pages if necessary.

_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________

I agree that all of the information on this form is accurate and true to the best of my knowledge.

Signature: _____________________________________            Date:  __________________________