Discrimination Complaint Form

Name

First

Last
Address

Street Address

City

ZIP / Postal Code
Phone
List other ways to contact you
Name and Location of person(s) or organization you are filing a complaint against:
Tell what Incident(s)happened that made you feel you had been discriminated against and the date(s) it/they occurred:
On what basis does the complainant believe he or she was discriminated against i.e., (age, sex, color, race or disability)?
List name(s), title(s), address(s) of person(s) having knowledge of discriminatory action(s).