Program Complaint Form - Office Of Diversity And Inclusion
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1
2Program Complaint Form
Office of Diversity and Inclusion
4201 Wilson Blvd., Suite 255S
Arlington, VA 22230
Complainant’s Information (Please Print or Type)
Complainant’s name (Last, First,
M.I.):
Home/mailing address:
City, State, Zip Code:
Daytime Telephone Number (with
area code);
E-mail address (if any)
Attorney/Representative Information (if any):
Attorney’s name:
Non-Attorney Representative
name:
Address:
City, State, Zip Code:
Telephone number (if applicable)
E-mail address (if any):
General Information:
Name of the person/ organization being
charged with discrimination:
Address of the person/organization begin
charged with discrimination:
Basis of the complaint resulting in the
__ Race
__ Gender
alleged discrimination:
__ Color
__ Age
__ National Origin
__ Disability
Has a similar complaint been filed
__ Yes
__ No
in another venue?
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