2. First Name*
3. Last Name*
5. Street Address*
6. Suite or Apartment Number
8. Mailing Address
   (if different from street address)
10. City*
11. State*
12. Zip Code*
14. Primary Phone*
15. Secondary Phone
17. Primary Phone Type*

    1. Home
    2. Work
    3. Mobile
18. Secondary Phone Type

    1. Home
    2. Work
    3. Mobile
20. Email Address*
21. Fax Number
23. Name of Complainant
    (If different from above)
25. Person/Agency you believe discriminated against you
27. First Name*
28. Last Name*
30. Title*
32. Name of the Company*
34. Street Address*
35. Suite or Apartment Number
37. City*
38. State*
39. Zip Code*
41. Primary Phone*
42. Secondary Phone
44. Primary Phone Type*

    1. Home
    2. Work
    3. Mobile
45. Secondary Phone Type

    1. Home
    2. Work
    3. Mobile
47. Email Address
48. Fax Number
50. Date of the alleged discriminatory act*
    Date of the alleged discriminatory act
52. Complaints of discrimination must be filed within 180 days of the date of the alleged discriminatory act. If the alleged act of discrimination occurred more than 180 days ago, please explain your delay in filing this complaint.
54. The alleged discrimination was based on:*

    1. Race
    2. Color

    1. Gender
    2. National Origin

    1. Disability
    2. Age

    1. Retaliation
56. Describe the alleged act(s) of discrimination*
58. Provide the names of any individuals with additional information regarding your complaint
60. Witness 1
62. First Name of Witness 1
63. Last Name of Witness 1
65. Street Address of Witness 1
66. Suite or Apartment Number
68. City
69. State
70. Zip Code
72. Primary Phone of Witness 1
73. Secondary Phone of Witness 1
75. Type

    1. Home
    2. Work
    3. Mobile
76. Type

    1. Home
    2. Work
    3. Mobile
78. Email Address of Witness 1
79. Fax Number
81. Brief description of the relevant information this witness may provide to support your complaint of discrimination.
83. Witness 2
85. First Name of Witness 2
86. Last Name of Witness 2
88. Street Address of Witness 2
89. Suite or Apartment Number
91. City
92. State
93. Zip Code
95. Primary Phone of Witness 2
96. Secondary Phone of Witness 2
98. Type

    1. Home
    2. Work
    3. Mobile
99. Type

    1. Home
    2. Work
    3. Mobile
101. Email Address of Witness 2
102. Fax Number
104. Brief description of the relevant information this witness may provide to support your complaint of discrimination.
106. Witness 3
108. First Name of Witness 3
109. Last Name of Witness 3
111. Street Address of Witness 3
112. Suite or Apartment Number
114. City
115. State
116. Zip Code
118. Primary Phone of Witness 3
119. Secondary Phone of Witness 3
121. Type

     1. Home
     2. Work
     3. Mobile
122. Type

     1. Home
     2. Work
     3. Mobile
124. Email Address of Witness 3
125. Fax Number
127. Brief description of the relevant information this witness may provide to support your complaint of discrimination.
129. How would you like your complaint to be resolved?*
131. Have you filed a complaint alleging the same discrimination with another state or federal agency?*

     1. Yes
     2. No
133. If yes, please provide the contact information for each agency.
135. First Agency Name
136. Date complaint filed
     Date complaint filed
138. Case number assigned to your complaint
139. Current status of your complaint
141. Second Agency Name
142. Date complaint filed
     Date complaint filed
144. Case number assigned to your complaint
145. Current status of your complaint
147. Third Agency Name
148. Date complaint filed
     Date complaint filed

     Date complaint filed
150. Case number assigned to your complaint
151. Current status of your complaint
153. Relevant documents
     Please attach any additional documents relevant to your complaint.
155. How did you learn about your right to file a discrimination complaint?*
157. Electronic Signature Agreement

     By checking the "I agree" box below, you agree and acknowledge that 1) your application 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.

     1. I agree.
159. Electronic Signature
Leave This Blank:


161. 1. Receive an email copy of this form.
162. Email address

     This field is not part of the form submission.

163. Submit Submit and Print

* indicates a required field