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Date of complaint: |
_____________________________________________________ |
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Name of Complainant: |
_____________________________________________________ |
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Are you filling out this form for yourself or someone else (please identify the individual if you are submitting on behalf of someone else): |
_____________________________________________________ _____________________________________________________ |
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Who or what entity do you believe discriminated against you (or someone else)? |
_____________________________________________________ |
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Date and place of alleged incident(s): |
_____________________________________________________ _____________________________________________________ _____________________________________________________ |
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Names of any witnesses (if any): |
_____________________________________________________ |
Nature of discrimination alleged (check all that apply):
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Age |
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Religion |
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Disability |
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Creed |
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Gender Identity |
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Sex |
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Marital Status |
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Sexual Orientation |
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National Origin |
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Socioeconomic Status |
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Race/Color |
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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: __________________________
