Today’s Date

Name
Address
City
State
Zip Code
Phone
Alternate Phone
E-mail

Why do you believe you were discriminated against? Please check all that apply.
Race
Color
National Origin
Religion
Sex
Family Status
Disability
Marital Status
Student Status
Age
Sexual Orientation
Gender Identity
I am not sure.

Please briefly describe what happened in the space below.

Who do you believe discriminated against you?
Name
Title or Position
Address
City
State
Zip Code
Phone
E-mail

When did the discrimination occur?
Date

Is it still happening?
Yes No