Name: 
Street Address:
Apt.#:
City or Town/State/Zip Code:
Phone:
Discrimination because of: __Race __Color __National Origin __Sex __Age __Disability __Other
Please provide the date(s) and location of the alleged discrimination, the name(s) of the
individual(s) who allegedly discriminated against you including their titles (if known).
Please provide the names, addresses and telephone numbers of any witnesses.
Explain as briefly and as clearly as possible what happened, how you feel that you were
discriminated against and who was involved. Please include how other persons were
treated differently from you.