Eligibility Complaint Of Discrimination Under The Provisions Of The California Fair Employment And Housing Act Template- California Department Of Fair Employment And Housing

* * * EMPLOYMENT * * *

COMPLAINT OF DISCRIMINATION UNDER

DFEH #

THE PROVISIONS OF THE CALIFORNIA

DFEH USE ONLY

F AIR EMPLOYMENT AND HOUSING ACT

CALIFORNIA DEPARTMENT OF FAIR EMPLOYMENT AND HOUSING

YOUR NAME (indicate Mr. or Ms.)

TELEPHONE NUMBER (INCLUDE AREA CODE)

ADDRESS

CITY/STATE/ZIP

COUNTY

COUNTY CODE

NAMED IS THE EMPLOYER, PERSON, LABOR ORGANIZATION, EMPLOYMENT AGENCY, APPRENTICESHIP COMMITTEE, OR STATE OR LOCAL GOVERNMENT

AGENCY WHO DISCRIMINATED AGAINST ME:

NAME

TELEPHONE NUMBER (Include Area Code)

ADDRESS

DFEH USE ONLY

│

│

CITY/STATE/ZIP

COUNTY

COUNTY CODE

│

│

NO. OF EMPLOYEES/MEMBERS (if known)

DATE MOST RECENT OR CONTINUING DISCRIMINATION

│RESPONDENT CODE

TOOK PLACE (month, day, and year)

│

THE PARTICULARS ARE:

I allege that on

, the

_____ termination

_____ denial of employment

_____ denial of family or medical leave

_____ lay-off

_____ denial of promotion

_____ denial of pregnancy leave

following conduct occurred:

_____ demotion

_____ denial of transfer

_____ denial of equal pay

_____ harassment

_____ denial of accommodation

_____ denial of right to wear pants

_____ genetic characteristics testing

_____ failure to prevent discrimination or retaliation

_____ denial of pregnancy accommodation

_____ constructive discharge (forced to quit)

_____ retaliation

_____ impermissible non-job-related inquiry

_____ other (specify) ____________________________________________

by

Name of Person

Job Title (supervisor/manager/personnel director/etc.)

_____ sex

_____ national origin/ancestry

_____ disability (physical or mental)

_____ retaliation for engaging in protected

because of:

_____ age

_____ marital status

_____ medical condition (cancer

activity or requesting a protected

_____ religion

_____ sexual orientation

or genetic characteristic)

leave or accommodation

_____ race/color

_____ association

_____ other (specify) ______________________________________________________

State what you

believe to be the

reason(s) for

discrimination

I wish to pursue this matter in court. I hereby request that the Department of Fair Employment and Housing provide a right-to-sue notice. I understand that if I want a federal notice of right-to-sue, I must visit

the U.S. Equal Employment Opportunity Commission (EEOC) to file a complaint within 30 days of receipt of the DFEH "Notice of Case Closure," or within 300 days of the alleged discriminatory act, whichever

is earlier.

I have not been coerced into making this request, nor do I make it based on fear of retaliation if I do not do so. I understand it is the Department of Fair Employment and Housing's policy to not process or

reopen a complaint once the complaint has been closed on the basis of "Complainant Elected Court Action."

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct of my own knowledge except as to matters stated on my information and

belief, and as to those matters I believe it to be true.

Dated

COMPLAINANT'S SIGNATURE

At

City

DATE FILED:

DFEH-300-03 (04/08)

DEPARTMENT OF FAIR EMPLOYMENT AND HOUSING

STATE OF CALIFORNIA