2. Complainant's Name
3. Email Address
5. Address
   Please include the Street Address. Apartment, suite, building information is optional.
7. City
8. State
9. Zip Code
11. Home Phone Number
12. Business Phone Number
16. Name of the person discriminated against (if other than the complainant)
18. Address
20. City
21. State
22. Zip Code
24. Which of the following best describes the reason you believe the discrimination took place? Was it because of your:

    1. Race
    2. National Origin
    3. Other
26. If you picked "other," please describe.
27. Date
    Date
29. In your own words, describe the alleged discrimination. Explain what happened and whom you believe was responsible.
31. Have you filed this complaint with any other federal, state, or local agency; or with any federal or state court?

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

    1. Federal agency
    2. Federal court
    3. State agency
    4. State court
    5. Local agency
35. Please provide name of a contact person at the agency / court where the complaint was filed.
37. Name
38. Email Address
40. Address
42. City
43. State
44. Zip Code
46. Phone Number
47. Fax Number
49. File Upload
    You may attach any materials or other information that you think is relevant to your complaint.
50. File Upload
    You may attach any materials or other information that you think is relevant to your complaint.
52. eSignature
    Please sign. (By signing, you agree and acknowledge that 1) your form will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.)
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54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit

* indicates a required field