Selective Service System
Discrimination/Harassment/Retaliation
Compliant Form
WWW.SSS.GOV/EEO
To file a complaint, complete and return to SSS EEO Office, 1515 Wilson Blvd., Arlington, VA 22209.
For more information, call (703) 605-4005 or (703) 605-4089.
Name:
Street Address:
City, State, Zip Code:
Date of Birth (if age discrimination):
Home Telephone Number: Office Telephone Number:
Work Location:
Email Address:
Nature of discrimination/harassment/retaliation:
Age
Color
Disability
National Origin
Race
Sexual Harassment
Gender
Date of alleged discrimination:
SSS Department/individual whom you believe has discriminated against you:
May we contact the department/individual?
Yes No
Describe alleged incident (use additional sheets if necessary):
Remedy requested:
The information provided above is true and correct to the best of my knowledge.
Signature and Date:
The EEO Office will contact you within 10 days from receipt of this form.
Selective Service System
. Office of Equal Employment Opportunity . 1515 Wilson Blvd., . Arlington, VA 22209
The Selective Service System is an equal opportunity, affirmative action employer providing employment without
regard to age, race, national origin, gender, religion, sexual orientation, veteran's status, political affiliation or
disability.
AUG-2015
click to sign
signature
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