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What was the discrimination based on? (check all that apply): <br />Race <br />Color <br />)National Origin <br />Date of Alleged Discrimination (Month, Day, Year: <br />Please describe in detail how you were discriminated against. Name any individual(s) <br />who was responsible, Attach addition sheets of paper if additional space is needed, <br />Section IV <br />Was this complaint filed with another Federal, State, or local agency; or with a Federal or <br />State Court? ( ) Yes ( )No <br />If yes, check each agency complaint was filed with: <br />Federal Agency Federal Court <br />State Court Local Agency Other (list) <br />State Agency <br />Provide contact person information for the agency you also filed the complaint with: <br />Name: <br />Address: <br />City: <br />Date Filed: <br />State: <br />You may attach any written materials or other information that you think is relevent to <br />your complaint. <br />Signature and date required below <br />Complainant's Signature <br />