2. Information about the person making the complaint
4. Name *
6. Address
8. City, State and Zip Code
10. Telephone Number(s)
11. Personal*
12. Business
14. Email Address
16. Information about the person discriminated against (if someone other than the complainant):
18. Name*
20. Address
22. City, State, Zip
24. Information about the discrimination incident
26. Which of the following best describes the reason you believe the discrimination took place? Was it because of: *

    1. Race / Color
    2. National Origin
    3. Other
28. What date did the alleged discrimination take place?
    What date did the alleged discrimination take place?

    If you are unsure of the date, leave it blank and provide information in the description below.

30. In your own words, describe the alleged discrimination. Explain what happened and whom you believe was responsible.*
32. Have you filed this complaint with any other federal, state, or local agency; or with any federal or state court? *

    1. Yes
    2. No
34. If yes, check all that apply:

    1. Federal agency
    2. Federal court

    1. State agency
    2. State court

    1. Local agency
36. If yes, please provide information about a contact person at the agency/court where the complaint was filed.
38. Name
40. Address
42. City, State, and Zip Code
44. Phone Number
45. E-mail
47. Additional Information

    You may attach and upload any written materials or other information that you think is relevant to your complaint.

49. Signature*

    Type your name above to constitute a digital signature.

Leave This Blank:


51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

53. Submit

* indicates a required field