Fillable Prince William County HUMAN RIGHTS COMMISSION

Fill Online, Printable, Fillable, Blank Prince William County HUMAN RIGHTS COMMISSION Form

Use Fill to complete blank online OTHERS (US) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Prince William County HUMAN RIGHTS COMMISSION

On average this form takes 18 minutes to complete

The Prince William County HUMAN RIGHTS COMMISSION form is 3 pages long and contains:

  • 0 signatures
  • 30 check-boxes
  • 58 other fields

Country of origin: US
File type: PDF

BROWSE OTHERS (US) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Prince William County
HUMAN RIGHTS COMMISSION
(703) 792-4680
www.pwcgov.org/humanrights
INTAKE QUESTIONNAIRE
1. Type of Alleged Discrimination (Only check those that apply)
Race _______________
Color _______________
Sex _______________
Pregnancy
National Origin ____________
Religion _____________
Gender:
Male
Female
Other
Sexual Orientation
Gender Identity
Disability
Genetic Information
Retaliation
Age (40
⁺
) DOB: ____________
Marital Status
Familial Status – Housing only
Status as a Veteran
2. Type of Complaint
3. Issue
(Check the box telling what your complaint is
about)
(For example: discharge, harassment, denial of
service, etc.)
Employment Credit Facilities
Housing
Education
Public Accommodation
4. Complainant/Charging Party
Name _____________________________________
Address ___________________________________
___________________________________________
Telephone (C) ______________________________
(H) ________________________________________
(W) _______________________________________
Email _____________________________________
---------------------------------------------------------------------------------------------
Employment Cases Only:
5. Position _________________________________
Rate of Pay: $____________________
Dates of employment:
_____________________ _____________________
From To
If you are not complainant, what is your relationship
Name ______________________________________
Address ____________________________________
____________________________________________
Telephone (C) _______________________________
(H) _________________________________________
(W) ________________________________________
Email ______________________________________
Relationship to complainant:
___________________________________________
Representative
6. Respondent/Organization
Name ____________________________________________________________________________
Address __________________________________________________________________________
__________________________________________________________________________________
Telephone ________________________________________________________________________
Number of Employees: 6 or more Fewer than 6
7. Your relationship to Respondent
☐
Employee
☐
Visitor/Customer/Invitee
☐
Student
☐
Tenant
Borrower
Representative
8. Who discriminated against you? (Include name(s), title(s), position(s).)
9. Last date of alleged discrimination?
10. Explain as briefly and clearly as possible what happened and how you were discriminated
against. Indicate who was involved and dates. Attach copies of any relevant documentation.
11. Why do you believe that you were being discriminated against?
12. List names & contact information for all witnesses that can support your allegations.
Name (First & Last Name) Contact (Address & Phone Number)
*Provide a brief summary of what each witness will testify.
13. What remedy are you seeking for the resolution of this complaint?
14. Have you ever filed charges with EEOC, Justice Department, or any other agency for this
same complaint?
Yes No Date:
15. Alternate contact information (relative, friend, etc.)
Name
Address
Telephone
IMPORTANT: The information you provide will be held confidential. The Respondent will
not be notified until you sign a formal complaint.
RETURN TO:
Prince William County
Human Rights Commission
15941 Donald Curtis Drive, Suite 125
Woodbridge, VA 22191-4256
www.pwcgov.org/humanrights
Telephone Number: (703) 792-4680
Fax Number: (703) 792-6944
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Prince William County HUMAN RIGHTS COMMISSION

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 1 May 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document