Nevada Equal Rights Commission

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

Mr/Mrs

First Name

Last Name

Date of Birth

Mailing Address

Street

Apt/Space/Room

City

State

Zip Code

Home Phone

Cell Phone

Do you need the assistance of an interpreter?
Click checkbox If YES, what language?

Section B

Company Name

Company Phone

Physical Address

Street

Apt/Space/Room

City

State

Zip Code

Section C

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

Relationship

Telephone

First Name

Last Name

Physical Address

Street

Apt/Space/Room

City

State

Zip Code

Section D

Hire Date

Last Date Worked

Date of alleged Discriminatory act

Present/ending position title

Present/Ending Pay

Per

Section G

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

First Name

Last Name

Job Title

First Name

Last Name

Job Title

First Name

Last Name

Job Title

Section H

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

First Name

Last Name

Number

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.

First Name

Last Name

City

State

Zip Code

Telephone Number

Address

First Name

Last Name

City

State

Zip Code

Telephone Number

Address

First Name

Last Name

City

State

Zip Code

Telephone Number

Address

Section J

Complete these sentences: *** All fields are required

1) I was hired by company on or about as a

While employed there, I was subject to

750 Character(s) Remaining

by my

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

2) The company explained that I was treated in this way because

750 Character(s) Remaining

3) I believe I was treated this way because

750 Character(s) Remaining

4) Explain the alleged discriminatory event(s) that you have marked in Section E. Please include who did what, who was there, what happened, when it happened, where it happened, what was said, etc. Please be as brief as possible

750 Character(s) Remaining

Please click here to read the disclaimer

I would like to download a copy of this submission (Optional)

Employment Discrimination Form

Employment Discrimination Form

Section A

Mailing Address

Section B

Physical Address

Section C

Physical Address

Section D

Section E

Section F

Section G

Section H

Section I

Section J