Public Accommodation Intake Form

 Please completely answer the following questions, telling us why you believe that you have been discriminated against in public accommodations.  Please use the TAB key to move through the fields.  Pressing enter will submit the form to the HRC.

Name

First Name Last Name Middle Initial
Address
City
State
Zip Code
Home Phone Number
Work Phone Number
Date of Birth
E-mail address
Race

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Other (Specify)
Ethnicity

Hispanic or Latino

Not Hispanic or Latino

AGAINST WHOM IS THIS COMPLAINT BEING FILED?

Name
Address
City
State
Zip Code
Telephone Number

If you have named an individual above and that individual appeared to be acting on behalf of a company, please complete the following information:

Company Name
Address
City
State
Zip Code
Telephone Number

Please utilize the space below to indicate identifying information on any additional entities or individuals related to the individual or company you named above and whom you think should be named in this complaint.  (Please indicate the address of the property involved in your complaint).

When did the act(s) occur? (Include the most recent date if several dates are involved)

What did the person you are complaining against do that you felt was discriminatory? 

Do you believe that the action taken against you was because of: (Check all that apply and specify, where applicable)

Race or Color National Origin
Black Hispanic
White Asian or Pacific Islander
Other (Specify) American Indian
Other (Specify)
Sex Disability
Male Physical
Female Mental
Religion Sexual Orientation/Gender Identity

Please list the names, addresses and telephone numbers for any individuals whom you believe would be able to provide information about the situation that you are complaining:

Name
Address
City/State/Zip
Telephone Number
Name
Address
City/State/Zip
Telephone Number
Name
Address
City/State/Zip
Telephone Number
Name
Address
City/State/Zip
Telephone Number

Please provide the name of an individual in the local area, who does NOT live with you, who would know how to reach you at any time.  This person must have a telephone number and a street address.

Name
Relationship
Address
City/State/Zip
Telephone Number

By submitting this information, you affirm that the information contained in your response to this Intake Form is true and correct to the best of your knowledge and belief.

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Last modified: 04 Sep 2022