Public Accommodation Discrimination Complaint Form

Public Accommodation Discrimination Complaint Form

Instructions for Completing: Public Accommodation 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 Accommodations NRS 651.

NOTE: Your complaint must be filed within 300 days from the last alleged discriminatory act.

Section A

Mr/Mrs Please Select One Mr. Mrs. Miss Ms.

First Name

Last Name

Date of Birth

Number & Street

Apt/Space

City

State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip Code

Email

Telephone (Home)

Cell Phone

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

AsstOfInterpreter

Language

Section B

Business Name

Company Phone

Physical Address

Street

Apt/Space/Room

City

State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip Code

Section C

Give the name of someone who can help us reach you.

Relationship

First Name

Last Name

Telephone

Physical Address

Street

Apt/Space/Room

City

State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip Code

Section D

Date of Incident

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.)

Race

Race

Race

Familial Status

Familial Status

Familial Status

Religion

Religion

Religion

Disability

Disability

DisabilityDetail

National Origin/Ancestry

National Origin/Ancestry

National Origin/Ancestry

Color

Color

Color

Sex

Sex

Sex

Sexual Orientation

Sexual Orientation

Sexual Orientation

Gender Identity or Expression

Gender Identity or Expression

Gender Identity or Expression

Section F

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

First Name

Last Name

Title they hold

First Name

Last Name

Title they hold

First Name

Last Name

Title they hold

Section G

List any witnesses to the alleged discrimination:

Witness 1

First Name

Last Name

Cell Phone

Home Phone

Email

Address

Witness 2

First Name

Last Name

Cell Phone

Home Phone

Email

Address

Witness 3

First Name

Last Name

Cell Phone

Home Phone

Email

Address

Section H

Briefly explain how you were treated

750 Character(s) Remaining

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