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Employment Discrimination Form

Employment Discrimination Form

Instructions for Completing: Employment Discrimination 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:

750 Character(s) Remaining

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.

Section J

Complete these sentences: *** All fields are required

750 Character(s) Remaining

750 Character(s) Remaining

750 Character(s) Remaining

750 Character(s) Remaining

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