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Human Relations Commission Intake Questionnaire - Public Accommodation

  1. Please answer the following questions, regarding why you feel you have been discriminated against in public accommodation within the city of Elgin.

  2. If other than Elgin, please enter city.

  3. If other than IL, please enter state.

  4. Examples of denial of public accommodation include:

    * Denial of full equal enjoyment of the services of a facility
    * Inaccessible route from entrance to the area where goods or services are provided
    * Lack of handicap parking
    * Inaccessible entrance/restrooms
    * Denied service based on the use of a guide, hearing, or support dog.

  5. The place of public accommodation or organization that you believe discriminated against you in public accommodation:

  6. If other than Elgin, please enter city.

  7. If other than IL, please enter state.

  8. The entity within Elgin that you believe discriminated against you is a:*

  9. Government Agency:*

  10. Thank you for submitting the form. We will contact you within a week.

  11. If you wish to receive an email copy of this form instead of printing, please check the box below and enter your email address.

  12. Leave This Blank:

  13. This field is not part of the form submission.