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State of Nevada

Department of Employment, Training & Rehabilitation

Nevada Equal Rights Commission

Before completing this form, please contact the nearest Equal Rights Commission Office for instructions

Phone (702) 486-7161
Phone (775) 823-6690

Discrimination Intake Form

The Nevada Equal Rights Commission is charged with the enforcement of employment, housing and public accommodations, state and federal discrimination laws, under NRS 233 and 613 inclusive; Title VII of the Civil Rights Act of 1964, as amended; Age Discrimination in Employment Act of 1967, as amended; and Equal Employment Opportunity Commission procedural regulations; housing NRS 118 and Public Announcement NRS 651.

NOTE: Your complaint must be filed within 300 days from the last alleged discriminatory act. The company against whom you are claiming discrimination must employ a total of 15 or more employees (total workforce - Nevada and elsewhere).

*** Fields marked with an asterisk "*" are required. *** Please enter all dates as: MM/DD/YYYY. Phone numbers - must enter area code.

Section A

Mailing Address

Section B

Physical Address

Section C

Give the name of someone who does not live with you and would be able to help us reach you.

Physical Address

Section D

Section E

This is a complaint of discrimination based upon:

(Mark only the reasons which you believe caused the discriminatory act(s) that you are claiming.)

If box checked, explanation is required in associated text box.

Section F

Mark only those actions allegedly taken against you AND the date of last alleged occurrence:

Section G

List the name(s) of the individual(s) that you are claiming were involved in the alleged discrimination:

Section H

What is the name of the company's Human Resources or Personnel Manager?

Section I

List the name(s) of anyone who witnessed, observed, and/or has knowledge of the event(s) that you are claiming were acts of discrimination. Give the names of those people who would willingly give a statement and would support you as your witness.

NOTE: All witness testimony in this process is voluntary.

Witness 1

Witness 2

Witness 3

Witness 4

Witness 5

Section J

Complete these sentences: *** All fields are required

After the last alleged discriminatory event, I filed my complaint with the Nevada Equal Rights Commission.

(To get a copy print before submitting)