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2. Please answer the following questions, regarding why you feel you have been discriminated against in public accommodation within the city of Elgin.
4. Date:*
5. First Name*
6. Last Name*
8. Address*
10. City*
    If other than Elgin, please enter city.
11. State*
    If other than IL, please enter state.
12. Zip*
14. Telephone Number:*
15. E-Mail Address:
16. 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.
19. The place of public accommodation or organization that you believe discriminated against you in public accommodation:
21. Name in Full:*
22. Illinois Address:*
24. City*
    If other than Elgin, please enter city.
25. State*
    If other than IL, please enter state.
26. Zip*
28. Phone Number:*
29. County:*
31. The entity within Elgin that you believe discriminated against you is a:*

    1. Bus or Train
    2. Restaurant/Bar
    3. Grocery Store
    4. Health Club

    1. Hotel/Motel
    2. Park or other public place of recreation
    3. Theater
    4. Other
33. If other, please specify:
35. Government Agency:*

    1. Federal
    2. State

    1. County
    2. City
37. Brief description of the event(s) leading up to the allegations of discrimination. (Include dates)*
39. Thank you for submitting the form. We will contact you within a week.
40. If you wish to receive an email copy of this form instead of printing, please check the box below and enter your email address.
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42. 1. Receive an email copy of this form.
43. Email address

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