Form Center

2. Please answer the following questions, briefly explaining why you feel you have been discriminated against in Employment.
4. Date:*
6. First Name:*
7. Last Name:*
9. Address:*
11. City:*
    If city is not Elgin, please type in city name.
12. State:*
    If state is not IL, please type in the state.
13. Zip:*
15. E-Mail Address:*
16. Telephone Number:*
18. I believe I was discriminated against by: (check all that apply)*

    1. Employer
    2. Union
    3. Other
20. Company Name:*
21. Contact Person:*
23. Address:*
25. City:*
26. State:*
27. Zip:*
29. Telephone Number:
31. The Human Relations Commission has jurisdiction over these categories listed below. By law, no other category can be investigated. Please check which category(ies), apply (ies) to your situation.*

    1. Age
    2. Ancestry
    3. Color
    4. Creed
    5. Familial Status

    1. Mental/Physical Handicap
    2. National Origin
    3. Race
    4. Religion
    5. Retaliation for assisting in an investigation of discrimination or for openly opposing unlawful discrimination based upon any categories listed above
33. Which action was taken against you that you believe to be discriminatory?

    1. Demoted
    2. Laid Off
    3. Not Hired
    4. Not Promoted

    1. Termination
    2. Transferred
    3. Unequal Wages
    4. Other
35. If other checked, please explain:
37. Briefly explain what happened and why you feel the above action or actions taken against you were discriminatory.*
39. What type of relief are you seeking?*
41. Thank you for submitting the form. We will contact you within a week.
43. If you wish to receive an email copy of this form instead of printing, please check the box below and enter your email address.
Leave This Blank:


45. 1. Receive an email copy of this form.
46. Email address

    This field is not part of the form submission.

47. Submit Submit and Print

* indicates a required field