Title VI & Civil Rights Complaint Form Name First Last Email Phone Home Address: Home Address: Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Discrimination Complaint Name of Staff Person that you Believe Discriminated Against You First Last Date of Alleged Incident You were discriminated against because of? Color National Origin Race Age Disability Sex Explain as briefly and clearly as possible what happened and how you were discriminated against. Indicate who was involved. Be sure to include how other persons were treated differently than you. Also attach any written material pertaining to your case such as any persons (witnesses, fellow employees, supervisors, or others), if known, whom we may contact for additional information to support or clarify your complaint. (Please be sure to provide contact information, and use additional sheets if necessary.) Upload a File: Unlimited number of files can be uploaded to this field.256 MB limit.Allowed types: jpg, jpeg, png, txt, pdf, doc, docx, xls, xlsx, zip. CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. What code is in the image? Enter the characters shown in the image. Get new captcha! Leave this field blank