Affirmative Action - Nys Department Of Motor Vehicles (Page 2 of 2) in pdf

Affirmative Action - Nys Department Of Motor Vehicles Page 2

Your claim of discrimination is based on: (Please check all that apply)

☐ Color

☐ National Origin

☐Race

☐Sex

☐Age

☐Disability

☐Limited English Proficiency

☐Income

Date(s) of alleged discrimination: __________________________________________________________________________________

Location where alleged discrimination took place: __________________________________________________________

Please briefly describe the circumstances of the alleged discrimination:

Click or tap here to enter text.

Witness name(s) and telephone number(s):

____________________________________________________

__________________________________________________________

____________________________________________________

__________________________________________________________

____________________________________________________

__________________________________________________________

Please attach any additional sheets of paper or documents which support your claims.

Have you filed a claim regarding this complaint with any federal, state, or local government agency? . . . ____

Have you instituted a legal suit or court action regarding this complaint? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ____

Have you hired an attorney with respect to the allegations in the complaint? . . . . . . . . . . . . . . . . . . . . . . . . . . . ____

I STATE THAT THE INFORMATION CONTAINED IN THIS CLAIM IS TRUE AND CORRECT TO THE BEST OF

MY KNOWLEDGE, INFORMATION, AND BELIEF.

____________________________________________________________________

____________________________________

Signature of Individual Filing Report

Date

Affirmative Action - Nys Department Of Motor Vehicles Page 2