Discrimination Complaint Form

Respondent Information

* First Name:
Middle Initial:
* Last Name:
Address:
City:
State:
Zip Code:
NCOM Affiliation:
* Phone Number:
* E-mail Address:
Complaint Information
Date and Time of Incident.
Name, Address and Telephone number of Business Refusing Service.
Name and Title of Person Refusing Service.
Did you give them a "Discrimination is Illegal" notice? If so, what happened?
What happened? (Give details and make statements as complete and accurate as possible.)
Witness Information
WITNESS # 1 - Name, Address, Telephone Number and Description of Involvement in Incident.
WITNESS # 2 - Name, Address, Telephone Number and Description of Involvement in Incident.
WITNESS # 3 - Name, Address, Telephone Number and Description of Involvement in Incident.
WITNESS # 4 - Name, Address, Telephone Number and Description of Involvement in Incident.
Additional Information
Were the Police Called? If so... Name of the Department Name of the Officers Badge Number of the Officers Describe the actions the Police took. If Citations, warnings, or complaints were filed, list the identification numbers.
Do you know if there have been other incidents of discrimination by this establishment? If so, please give any details such as who was involved, how to contact them, and when incidents took place.
Would you be willing to pursue this claim through the courts?
What other important information would you include in this report?
* Anti-spam question: