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Discrimination Complaint Form <br /> rg- Ntatorou:: <br /> *pm r24,4v*,- - ":41TetC7 „:41AN <br /> Name: <br /> Address: <br /> Telephone(Home): Telephone(Work): <br /> Electronic Mail Address: <br /> Large Print 0 Audio Tape El <br /> Accessible Format Requirements? TDD 0 Other 0 <br /> Are you filing this complaint on your own behalf? Yes* El No El' <br /> *Ifyou answered "yes"to this question, go to Section III <br /> If not,please supply the name and relationship of <br /> the person for whom you are complaining. <br /> Please explain why you have filed for a third party: <br /> Please confirm that you have obtained the permission of the <br /> aggrieved party if you are filing on behalf of a third party. <br /> 0 Yes El No <br /> ' 4444”W.-:t"'4;`.44V444144, -44;4," ,,4,4f440,41411- <br /> 1 believe the discrimination I experienced was based on(check all that apply): <br /> Race D Color 0 National Origin CI <br /> Date of Alleged Discrimination(Month,Day,Year): Click or tap here to enter text. <br /> Explain as clearly as possible what happened and why you believe you were discriminated <br /> against. Describe all persons who were involved. Include the name and contact information <br /> of the person(s)who discriminated against you(if known)as well as names and contact <br /> information of any witnesses. If more space is need, please use the back of this form. <br /> Have you previously filed a discrimination complaint with this <br /> agency? 0 Yes 0 No <br /> • <br /> 12 <br />