Eligibility Complaint Of Discrimination Under The Provisions Of The California Fair Employment And Housing Act Template- California Department Of Fair Employment And Housing Page 2
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1
2RIGHT-TO-SUE COMPLAINT INFORMATION SHEET
DFEH needs a separate signed complaint for each employer, person, labor organization, employment agency, apprenticeship committee, state or local
government agency you wish to file against. If you are filing against both a company and an individual(s), please complete separate complaint forms naming
the company or an individual in the appropriate area.
Please complete the following so that DFEH can process your complaint and for DFEH for statistical purposes, and return with your signed
complaint(s):
YOUR GENDER: __ Female __ Male
YOUR RACE:/ETHNICITY (Check one)
__ African-American
YOUR OCCUPATION:
__ African - Other
__ Clerical
__ Asian/Pacific Islander (specify)___________
__ Craft
__ Caucasian (Non-Hispanic)
__ Equipment Operator
__ Native American
__ Laborer
__ Hispanic(specify)____________________
__ Manager
__ Paraprofessional
YOUR PRIMARY LANGUAGE (specify)
__ Professional
_______________________________________
__ Sales
__ Service
YOUR AGE:
__ __
__ Supervisor
__ Technician
IF FILING BECAUSE OF YOUR NATIONAL ORIGIN/ANCESTRY,
YOUR NATIONAL ORIGIN/ANCESTRY (specify)
HOW YOU HEARD ABOUT DFEH:
_______________________________________
__ Attorney
IF FILING BECAUSE OF DISABILITY,
__ Bus/BART Advertisement
YOUR DISABILITY:
__ Community Organization
__ AIDS
__ EEOC
__ Blood/Circulation
__ EDD
__ Brain/Nerves/Muscles
__ Friend
__ Digestive/Urinary/Reproduction
__ Human Relations Commission
__ Hearing
__ Labor Standards Enforcement
__ Heart
__ Local Government Agency
__ Limbs (Arms/Legs)
__ Poster
__ Mental
__ Prior Contact with DFEH
__ Sight
__ Radio
__ Speech/Respiratory
__ Telephone Book
__ Spinal/Back
__ TV
__ DFEH Web Site
IF FILING BECAUSE OF MARITAL STATUS,
YOUR MARITAL STATUS: (Check one)
DO YOU HAVE AN ATTORNEY WHO HAS AGREED TO
__ Cohabitation
REPRESENT YOU ON YOUR EMPLOYMENT DISCRIMINATION
__ Divorced
CLAIMS IN COURT? IF YOU CHECK “YES”, YOU WILL BE
__ Married
RESPONSIBLE FOR HAVING YOUR ATTORNEY SERVE THIS
__ Single
DFEH COMPLAINT.
IF FILING BECAUSE OF RELIGION,
__ Yes
__ No
YOUR RELIGION: (specify)
____________________________________
PLEASE PROVIDE YOUR ATTORNEY’S NAME, ADDRESS AND
PHONE NUMBER:
IF FILING BECAUSE OF SEX, THE REASON:
__ Harassment
__ Orientation
_______________________________________
__ Pregnancy
__ Denied Right to Wear Pants
_______________________________________
__ Other Allegations (List) ________________________
DFEH-300-03-1 (04/08)
_______________________________________
Department of Fair Employment and Housing
Your Signature
Date
State of California
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