Discrimination Complaint Form

 

Respondent Information

* First Name:
Middle Initial:
* Last Name:
Address:
City:
State:	- Choose State - AL-Alabama AK-Alaska AZ-Arizona AR-Arkansas CA-California CO-Colorado CT-Connecticut DE-Delaware D.C.-Dist. of Columbia FL-Florida GA-Georgia HI-Hawaii ID-Idaho IL-Illinois IN-Indiana IA-Iowa KS-Kansas KY-Kentucky LA-Louisiana ME-Maine MD-Maryland MA-Massachusetts MI-Michigan MN-Minnesota MS-Mississippi MO-Missouri MT-Montana NE-Nebraska NV-Nevada NH-New Hampshire NJ-New Jersey NM-New Mexico NY-New York NC-North Carolina ND-North Dakota OH-Ohio OK-Oklahoma OR-Oregon PA-Pennsylvania RI-Rhode Island SC-South Carolina SD-South Dakota TN-Tennessee TX-Texas UT-Utah VT-Vermont VA-Virginia WA-Washington WV-West Virginia WI-Wisconsin WY-Wyoming
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:

   

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