Discrimination Complaint Form
Please use this form to submit a discrimination complaint.
Full Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of Incident
-
Month
-
Day
Year
Date
Location of Incident
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Description of the Incident
Were there any witnesses? (Check all that apply)
Yes
No
Other
Witness Names
First Name
Last Name
Nature of Discrimination
Please Select
Race
Gender
Age
Disability
Religion
Sexual Orientation
National Origin
Other
Please provide any supporting evidence (documents, photos, etc.)
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