Civil Rights Forms

Equal Employment Opportunities (EEO) Program (Title VII)

for: Current Employees or Applicants.

Submissions may be made by current employees, applicants or a third party on behalf of those individuals. Please provide as much information as possible.

Employee / Applicant Name

Address

City

State

Zip

Home Phone #

Office Phone #

Cell Phone #

Incident Date

What was the discrimination based upon? (Check all that apply)

Sex
Race
Color

National Origin
Religion
Other

Description of Discrimination

Please provide witness contact information (if any).

Witness 1

Name

Home Phone #

Address

City

State

Zip

Witness 2

Name

Home Phone #

Address

City

State

Zip

Third Party Contact Info

Does the employee/applicant know you are submitting a complaint on their behalf?

Yes

If you would like to remain anonymous, please skip the section below.

Name

Address

City

State

Zip

Home Phone #