1. Full Legal Name:
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2. Address:
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3. City: State: Zip Code:
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Phone Number: Alternate Phone:
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| E-Mail Address: |
4. Please check the AREA in which you are filing your complaint.
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Check the Basis(es) or reason(s) you believe the negative action was taken against you.
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5. Who do you believe discriminated against you? (Give the FULL LEGAL name of person, employer, public accommodation, or other entity, address and telephone number.)
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6. If number 5 is owned by another company, please give the FULL LEGAL name, address and telephone number of the owner.
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| 7. Give the approximate number of full and part-time employees (employment cases). |
| 8. filed this complaint with any other agency? |
If YES, what agency(s)?
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When were they Contacted:
[None]   |
| 9. The last date something negative happened to you.
[None] |
10. Please explain the particulars of your complaint below. Remember to state why you feel you were discriminated against.
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| advise the Commission if I change my address or telephone number and to cooperate fully with them in the processing of my charge in accordance with their procedures. |
| that I have read the above charge and that it is true to the best of my knowledge, information and belief. |