U.S. EQUAL EMPLOYMENT OPPORTUNITY COMMISSION
Please immediately complete this entire form and return it to the U.S. Equal Employment Opportunity
Commission (“EEOC”). REMEMBER, a charge of employment discrimination must be filed within the
time limits imposed by law, within 180 days or in some places within 300 days of the alleged discrimination. When we receive
this form, we will review it to determine EEOC coverage. Answer all questions completely, and attach additional pages if
needed to complete your responses. If you do not know the answer to a question, answer by stating “not known.” If a
question is not applicable, write “N/A.” (PLEASE PRINT)
1. Personal Information
Last Name: _______________________________ First Name: _______________________________ MI: _________________
Street or Mailing Address: _______________________________________________ Apt or Unit #: ______________________
City: _____________________________ County: ____________________ State: _________ Zip: _______________________
Phone Numbers: Home: (_____) _________________________ Work: (_____) ______________________________________
Cell: (_____) _________________________ Email Address: ______________________________________________________
Date of Birth: ______________
Do You Have a Disability?
Please answer each of the next three questions.
i. Are you Hispanic or Latino?
ii. What is your Race?
Please choose all that apply.
American Indian or Alaskan Native
Black or African American
Native Hawaiian or Other Pacific Islander
iii. What is your National Origin (country of origin or ancestry)? ___________________________________________________
Please Provide The Name Of A Person We Can Contact If We Are Unable To Reach You:
Address: __________________________________ City: ____________________ State: ______ Zip Code: ________________
Home Phone: (____) _________________________ Other Phone: (____) _________________________
2. I believe that I was discriminated against by the following organization(s): (Check those that apply)
Other (Please Specify) ___________________________________
Organization Contact Information (If the organization is an employer, provide the address where you actually worked. If you
work from home, check here
and provide the address of the office to which you reported.) If more than one employer is
involved, attach additional sheets.
Organization Name: _______________________________________________________________________________________
Address: ________________________________________ County: _________________________________________________
City: ____________________________ State: ____ Zip: ____________ Phone: (____) _________________________________
Type of Business: __________________ Job Location if different from Org. Address: __________________________________
Human Resources Director or Owner Name: ____________________________________ Phone: (____) ___________________
Number of Employees in the Organization at All Locations: Please Check (√) One
Fewer Than 15
15 – 100
101 – 200
201 – 500
More than 500
3. Your Employment Data (Complete as many items as you are able.) Are you a federal employee?
Date Hired: ________________________ Job Title At Hire: ______________________________________________________
Pay Rate When Hired: _________________________ Last or Current Pay Rate: ______________________________________
Job Title at Time of Alleged Discrimination: _______________________ Date Quit/Discharged:_________________________
Name and Title of Immediate Supervisor: _____________________________________________________________________
If Job Applicant, Date You Applied for Job ______________ Job Title Applied For __________________________________