EMPLOYMENT HISTORY (Current/Most Recent Employer First)
INFORMATION REGARDING YOUR CLAIM
This is the individual or business that you believe discriminated against you or treated you wrongly.
Max. file size: 256 MB.
Drop files here or
List all person(s) that you believe discriminated against you or treated you wrongly.
WHEN & WHY
If you were fired, state the reason given by your employer. If you resigned, state the reason you gave to your employer.
DESCRIPTION OF INCIDENT
NAME | GENDER | JOB TITLE | RACE | AGE | HOW
FOLLOW-UP QUESTIONS - EMPLOYMENT-RELATED ONLY (continued)
OTHER GENERAL INFORMATION
Answer the following questions to the best of your ability.
If your answer to ANY of these questions is YES please explain below when prompted.
ANSWERS TO OTHER GENERAL INFORMATION QUESTIONS
If your answer to any of the previous questions is YES, please explain below with the Number of the Question first.
USE THIS SPACE to describe all persons that you believe have knowledge regarding your claim of discrimination. Include people you think will support you and people you think are against you.
Important Document Information
Please list the name/info of the documents and who has it
Signature and Current Date