Civil Rights Law Questionnaire

Your full name

Street address

Apartment, suite, etc.

City

State—Please choose an option—AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming

Zip code

Email address

Telephone number *

Your date of birth *

Last 4 digits of your SSN

Employer name

Employer address

Your job title

Salary/wage rate *

How did you hear about us? *InternetYelpFriendPhone bookOther

Describe in detail the events that gave rise to your claim. Explain the nature of the harm you believe you have suffered and the dates of the harm. *

How have you been damaged by these events? *

Please provide the name(s) and address(s) of the person(s) or entity you believe you have a claim against.

Have you filed administrative charges relating to your claim OCR, EHOC, the EEOC and/or the Missouri Commission on Human Rights or Illinois Department of Human Rights or any other administrative agency?
Please check which one. *OCREHOCEEOCMissouri Commission on Human RightsIllinois Department of Human RightsOtherNone of the above

State the date you received any decision or "right to sue" letter from any of the agencies described above. We would also request a copy of any such letter.

List the names and contact information for any witnesses to your claim.

List any ADDITIONAL information you think we should know regarding your claim

Do you accept or do you not accept this disclaimer? *I acceptI don't accept