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Complainant Information
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Contact Person
Provide the contact information for a person who does not live with you but can contact you.
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The name and contact information for the attorney representing you in this matter (if any):
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Employer:
Provide the contact information for the person you would like to file a complaint against.
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Employment Information
Complete this section if you are a current or former employee
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Applicant For a Job/Promotion
Complete this section if you were discriminated against when you applied for a job or promotion.
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Protected Classes
Please check all that apply.
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Witness Information
List the name(s) and contact information of anyone who has first-hand knowledge of the harm(s) you are alleging.
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Current and Previous Employees
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