Fillable EMPLOYMENT DISCRIMINATION COMPLAINT FORM Texas Workforce Commission Civil (Texas Real Estate Contracts)

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EMPLOYMENT DISCRIMINATION COMPLAINT FORM Texas Workforce Commission Civil (Texas Real Estate Contracts)

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The Texas Real Estate Commission (TREC) is an agency that governs real estate practices in the state of Texas USA. I its headquarters are located in Ausin Texas at 1700 North Congress.

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EMPLOYMENT DISCRIMINATION COMPLAINT FORM
Texas Workforce Commission Civil Rights Division
Please return this form by:
Mail: 101 East 15th Street, Guadalupe CRD, Austin, TX 78778-0001
Email: EEOIntake@twc.state.tx.us
Telephone: (888) 452-4778 or
Fax: (512) 463-2643 or (512) 463-2755
included.)
TWCCRD#________________
EEOC#____________________
Please indicate if you have previously filed this complaint with any of the
agencies below:
Texas Workforce Commission Civil Rights Division (TWCCRD)
Equal Employment Opportunity Commission (EEOC)
City of Austin Equal Employment and Fair Housing Office
Corpus Christi Human Relations Division
Fort Worth Human Relations Department
DATE RECEIVED (For Office Use Only):
Please be sure you provide all the information requested. For Assistance, send an E-mail to EEOIntake@twc.state.tx.us or call us at (888) 452-
4778. (Ofrecemos asistencia en Español)
Complainant Full Name:
Address Line 1:
Address Line 2:
City/State/Zip:
Home Phone #:
Other Phone #:
Email:
Complainant Representative (Optional): (If you are represented by an attorney,
please have them submit a letter of representation):
Address Line 1:
Address Line 2:
City/State/Zip:
Phone #:
Fax #:
Preferred Form of Contact: (Please check)
E-mail Telephone
Date Hired: Position held:
Still employed? Yes No
HR Personnel Officer/EEO Officer/or Highest Ranking Officer on work site:
Name of Employer (Please be sure to give the complete Company
name and address where you physically worked)
15 or more employees:
Yes No
Company Address
Address Line 1:
Address Line 2:
City/State/Zip:
Phone #:
Company Officer Address
Address Line 1:
Address Line 2:
City/State/Zip:
Phone #:
BASIS: I believe I have been
discriminated against in violation of
state law (Texas Labor Code, Chapter
21) and federal law (ADEA, GINA, Title
VII, ADAAA), as follows:
Age (You must be 40
years of age or older to
qualify):
Date of Birth:
/ /
Month/day/year
Age at time of incident:
Color (Based on skin color):
Black
Brown
White
Other:
Disability:
Disabled
History of disability
Regarded as disabled
(Pregnancy is NOT a disability unless you are
regarded as disabled.)
Please mark only the basis
you believe were the reasons
you were discriminated.
GINA
(Genetic Information Non-
discrimination Act)
National Origin:
African-American
Anglo/Caucasian
East Indian
Hispanic
Mexican
Other:
Race:
American Indian/Alaskan Native
Asian/Pacific Islander
Black
White
Other:
EXAMPLE: If your treatment
was because of your race, then
check only the box by your race.
Religion:
Baptist
Catholic
Jewish
Muslim
Other:
Retaliation:
Assisted another filing discrimination
Filed a complaint of discrimination
Participated in discrimination
investigation.
ON THIS DATE:
/ /
Month/day/year
Sex:
Female
Female/Pregnancy
Male
Revised: 03/2017
Demotion (D1)
Discharge (D2)
Discipline (D3)
Harassment (H1)
Hiring (H2)
Layoff (L1)
Promotion (P3)
Reasonable Accommodation (R6)
Severance Pay (B5)
Sexual Harassment (S4)
Suspension (S5)
Terms & Conditions (T2)
Training (T4)
Wages (W1)
Other:
(Each incident must be within 180 days of the date you submit your complaint to the TWCCRD.)
Earliest (Month/Day/Year) Latest (Month/Day/Year)
/ / / / CONTINUING ACTION
Name and Position Title of person(s) who did the harm:
(If filing under race, color, national origin, religion, sex, age,
please provide the race, color, national origin, religion, sex, or age of the person(s)
discriminating against you:)
Did you complain of discrimination to your employer? Yes No
If Yes, date of complaint: / / (Month/Day/Year)
Name and Position Title of person(s) you complained to:
Explain why you believe the employment harm(s) and/or action(s) were discriminatory:
Employer’s reason for its action:
Are there other employees treated more fairly than you? Yes No
If Yes, please provide the information below:
Full Name and Position Title
(If filing under race, color, national origin, religion, sex, and/or age, please
provide the race, color, national origin, religion, sex, or age of the person(s) treated
more fairly than you.)
Email: Telephone: ( )
Submitting this Complaint Form DOES NOT represent filing a formal Charge of Discrimination
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EMPLOYMENT DISCRIMINATION COMPLAINT FORM Texas Workforce Commission Civil (Texas Real Estate Contracts)

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Completed 26 April 2021

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