1. Full Legal Name:

2. Address:

3. City:  State: Zip Code:

Phone Number:  Alternate Phone: 

 E-Mail Address:

4. Please check the AREA in which you are filing your complaint.


Check the Basis(es) or reason(s) you believe the negative action was taken against you.

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.)

6. If number 5 is owned by another company, please give the FULL LEGAL name, address and telephone number of the owner.   

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)?
When were they Contacted:  [None] Select a Date Delete the Date  
9. The last date something negative happened to you.   [None] Select a Date Delete the Date  
10. Please explain the particulars of your complaint below. Remember to state why you feel you were discriminated against.
 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.