I Believe I Was Discriminated Against By

Enter information about the individual or organization you believe discriminated against you.

Show Title as Legend:
Yes

Discriminator's Prefix

Enter the chosen prefix of the person you believe discriminated against you.

Discriminator's First Name

Enter the first name of the person you believe discriminated against you.

Discriminator's Middle Initial

If applicable enter the middle initial of the person you believe discriminated against you.

Discriminator's Last Name

Enter the last name of the person you believe discriminated against you.

Organization

Enter the name of the organization you believe discriminate against you.

Discriminator's Address

Enter the street address of the person you believe discriminated against you.

Discriminator's City

Enter the city for the address of the person you believe discriminated against you.

Discriminator's State

Enter the state for the address of the person you believe discriminated against you.

Discriminator's Zip Code

Enter the zip code for the address of the person you believe discriminated against you.

Discriminator's Email Address

Enter the email address of the person you believe discriminated against you.

Discriminator's Work Phone

Enter the work phone number of the person you believe discriminated against you. Use format xxx-xxx-xxxx.

This person is a

Select the option that best describes the person you think discriminated against you.