If you feel you have experienced discrimination, please fill out and submit the following form.
*This is a required field to fill out.
*Today's date
*First Name *Last Name
*Address
*City *State
*Zip Code
*Phone Alternate Phone
E-mail
Who can we contact if we cannot reach you?
Name Phone Number
Email
Why do you think you were discriminated against? Please check all that apply.
Race Color National Origin Religion Sex or Gender
Children Disability Age Sexual Orientation
Marital Status Military Status Source of Income
Gender Identity and Expression
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 Number
When did the discrimination occur?
Date
Is it still happening?
Yes No