INTAKE EQUAL ACCOMMODATION DISCRIMINATION COMPLAINT

	1. NAME OF AGGRIEVED PERSON OR ORGANIZATION
Prefix	Mr. Mrs. Miss Ms.
Name	(last name, first name, middle initial)
Address
City
County
State
Zip
Home Phone:
Business Phone:
	NAME OF CONTACT PERSON
Prefix	Mr. Mrs. Miss Ms.
Name	(last name, first name, middle initial)
Address
City
County
State
Zip
Home Phone:
Business Phone:
Email:	Reguired. Must be completed.
	2. AGAINST WHOM IS THIS COMPLAINT BEING FILED?
Prefix	Mr. Mrs. Miss Ms.
Name	(last name, first name, middle initial)
Address
City
County
State
Zip
Home Phone:
Business Phone:
	Name and identify others (if any) you believe violated the law in this case:
	3. WHAT DID THE PERSON AGAINST WHOM THE COMPLAINT WAS FILED DO? CHECK ALL THAT APPLY AND GIVE THE MOST RECENT DATE THESE ACT(S) OCCURRED IN BLOCK NO. 6b BELOW
	Were you refused, withheld or denied accommodations, facilities, advantages or privileges of a place of equal accommodations?
	Did the person against whom the complaint was filed, directly or indirectly publish, issue, circulate, post or display any radio communication, notice or advertising indicating that equal accommodation in the classes listed in block No. 4 below is not welcomed, desired or solicited?
	Did someone assist, induce or coerce another person to commit any discriminatory equal accommodations practice prohibited by the Equal Accommodations law?
	4. DO YOU BELIEVE THAT YOU WERE DISCRIMINATED AGAINST BECAUSE OF YOUR RACE, COLOR, AGE, DISABILITY, MARITAL STATUS, NATIONAL ORIGIN, CREED? CHECK ALL THAT APPLY:
	Race or Color Black White Other
	Age (specify)
	Sex Male Female
	Disability Physical Mental
	Marital status (specify)
	National Origin (specify)
	Creed (specify)
	5. What kind of business establishment or facility was involved?
	Restaurant
	Department Store
	Bank
	Supermarket
	Other (Specify)
	5b. Do you wish to utilize the goods, products or services of this facility?
	Yes
	No
	6a. Summarize in your own words what happened. Use this space for a brief and concise statement of facts (who, what, when, where, now).
	6b. When did the act(s) checked in Item 3 occur? (Include the most recent date if several dates are involved)
	7. How did you find out about the Division of Human Relations?

Last Updated: Thursday, 31-Jan-2008 15:55:21 EST