Individual Complaint Of Employment Discrimination Page 3
Download a blank fillable Individual Complaint Of Employment Discrimination in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Individual Complaint Of Employment Discrimination with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4Form No. TDF 62-03.5
FOR OFFICE USE ONLY
(01/03 Edition)
DEPARTMENT CASE NUMBER
INDIVIDUAL COMPLAINT OF EMPLOYMENT DISCRIMINATION
FILING DATE
/
/
WITH THE DEPARTMENT OF THE TREASURY
Part I Complainant Identification
5. Name and Address of Organization Where You Work (If a
1. Name (Last, First, Middle Initial)
Treasury Employee)
Bureau
2. Telephone/Fax (Include Area Code)
Business Unit
Home:
Fax:
Fax:
Work:
Office and Organizational Component
3. Present Home Address (You must notify the Department of
any changes of address while complaint is pending, or your
Street Address
complaint may be dismissed)
City
State
Zip Code
Street Address
6. Employment Status in Relation to this Complaint:
Applicant
Probationary
Career/Career Conditional
/
/
City
State
Zip Code
Former Employee
Date Left Treasury Employment
4. If you are a current or former employee of the Federal
/
/
Retired
government, list your most recent title, series, and grade.
Date of Retirement
Other
Specify
Title
Series
Grade
7. I certify that all of the statements made in this complaint are true, complete, and correct to the best of my knowledge
and belief.
/
/
Date
Signature of Complainant or Attorney Representative
Part II Designation of Representative
8. You may represent yourself in this complaint or you may choose someone to represent you. Your representative does
not have to be an attorney. You may change your designation of a representative at a later date, but you must notify
the Department immediately in writing of any change, and you must include the same information requested in this
Part.
(Please Print Name) to serve as
" I hereby designate
my representative during the course of this complaint. I understand that my representative is authorized to
act on my behalf. "
10. Representative's Employer (If Federal Agency)
9. Representative's Mailing Address
Representative's Telephone/Fax (Include Area Code)
11.
Firm/Organization
Telephone
Fax
Street Address
/
/
City
State
Zip Code
12. Complainant's Signature
Date
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal