Fillable Mark Brnovich Ofce of Arizona Attorney General (Arizona Attorney General)

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Mark Brnovich Ofce of Arizona Attorney General (Arizona Attorney General)

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Ofce of Arizona Attorney General
Mark Brnovich
2005 N Central Avenue, Phoenix, AZ 85004
Your Information Person/Business in Complaint
Name: Name:
Address: Address:
City: City:
State: State:
Zip: Zip:
Phone: Phone:
Please indicate which of the following categories applies to your complaint against the person or busi-
ness listed in the section above. Circle all areas that you believe apply to your situation.
Employment Housing Public Accommodations Voting
Race
Color
National Origin
Religion
Sex/Gender
Age
Disability
Retalation
Genetic Information
Race
Color
National Origin
Religion
Sex/Gender
Disability
Familial Status
Retaliation
Race
Color
National Origin
Religion
Sex/Gender
Ancestry
Disability
Retaliation
Race
Color
National Origin
Religion
Sex/Gender
Ancestry
Disability
When did the act or incident you are complaining about take place?
First Time: Last Time: Continuous: (Yes or No)
Civil Rights Intake Questionnaire
Ofce of Arizona Attorney General
Mark Brnovich
2005 N Central Avenue, Phoenix, AZ 85004
Civil Rights Intake Questionnaire Continued
Thoroughly explain what happened to you. State what happened, when it happened, the names
of people involved, names of witnesses, and any other information. Please tell your story of what
happened to you from the beginning to the end. Also, please attach to this questionnaire any
documents that will help explain what happened to you.
Have you led a complaint with any other federal, state, or local agency to complain about this dis-
crimination? If the answer is yes, please state the name and address of the agency.
Do you have an attorney? If the answer is yes, please tell us the name and address of your attorney.
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Mark Brnovich Ofce of Arizona Attorney General (Arizona Attorney General)

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Completed 20 July 2020

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