Discrimination Information Center

Discrimination Contact Form

Name

Email Address

Phone Number

Business Phone

Cellular or Pager

Address

City

State

Zip

If you experienced discrimination in the workplace, what is your employer's name?

Employer's address, including county.

What type of business is it? (solo proprietorship, LLC, etc.)

If you experienced discrimination elsewhere, please describe where and under what circumstances the discrimination took place:

Please describe the discriminatory treatment:

If discrimination occurred in the workplace, are you still employed by this employer?
Yes  No 

If no, does the nature of your claim relate to wrongful termination?
Yes  No 

If yes, please describe:

If the discrimination relates to age, please provide us with your age:

Are you over 40 years of age?
Yes  No 

Please list any disabilities that you have:

If the discrimination relates to race or national origin, please list your race or national origin:

If the claim relates to harassment, please discuss the circumstances surrounding the allegations:

If the claim involves disparate wage treatment, please give:

Wages you were paid for the period involved:

Wages claimed:

Wage paid to others working performing same or similar tasks with similar training or experience:

Special concerns:

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