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  1. Do you wish to remain anonymous?*
  2. Discrimination alleged (check all that may apply)?*
  3. Race of Complainant:*
  4. Please explain your complaint as clearly as possible. Include how other persons were treated differently. Use additional sheet(s) if necessary. Attach supporting documents if available.

  5. Please include the earliest date of discrimination and the most recent date(s) of discrimination.

  6. The law prohibits intimidation or retaliation against anyone because they have either taken action, or participated in action, to secure rights protected by the laws. If you feel that you have been retaliated against, separate from the discrimination alleged above, please explain the circumstances above. Describe the action you took which you believe was the cause for the alleged retaliation.

  7. Name(s) of individual(s) responsible for the discriminatory action(s).

    Name(s) of person(s) who may be contacted for additional information to support or clarify your complaint. (Attach additional sheets, if necessary).

  8. What action(s) have you or your representative done to attempt to resolve this complaint?
  9. Please include filing dates or other dates as applicable that correspond with the numbers above.
  10. Please type name in the above field.

  11. Leave This Blank:

  12. This field is not part of the form submission.