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2. Complainant*
4. Street Address*
6. City*
7. State*
8. Zip Code*
10. Complainant's Phone Number*
11. Complainant's Email Address*
13. Is the Complainant the same person being discriminated against?*

    1. Yes
    2. No
17. Person Discriminated Against (If Different From Above)
19. Address
21. City
22. State
23. Zip Code
25. Phone Number
26. Email Address
30. What is the full legal name of the organization that discriminated against you?*
32. Type of Discrimination*

    1. Race/Color
    2. National Origin
    3. Retaliation
33. Date of Incident*
    Date of Incident
35. Date and place of alleged discriminatory actions. Please include earliest date of discrimination and most recent date of discrimination.*
37. Explain as briefly and clearly as possible what happened and how you were discriminated against. Indicate who was involved. Be sure to include how other persons were treated differently than you. Also, attach any written material pertaining to your complaint (attach additional pages if necessary).*
39. Additional Document (If Needed)
41. Names and contact information of persons (witnesses, others) whom we may contact for additional information to investigate your complaint.*
45. The complaint will not be accepted if it is had not been signed with an electronic signature. Please sign and date this complaint form here. You may attach any written materials or other supporting information that you believe is relevant to the complaint.
47. Electronic Signature*
48. Date*
    Date
50. Do you have attachments?*

    1. Yes
    2. No
52. Attach Related Information
53. Attach Related Information
54. Attach Related Information
Leave This Blank:


59. 1. Receive an email copy of this form.
60. Email address

    This field is not part of the form submission.

61. Submit

* indicates a required field