Who else can we call, if we cannot reach you?
Please provide a short summary of your discrimination complaint below:
Date of last alleged act of discrimination: Select Month January February March April May June July August September October November December Select Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Select Year 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Is the alleged discrimination ongoing? Yes No
Please indicate all of the following categories that apply to your complaint against the person or business listed above:
Employment
Race Color National Origin Religion/Creed Sex/Gender (Includes Pregnancy, Sexual Harassment) Age (40 Years or Older) Disability Genetic Information Retaliation
Housing
Race Color National Origin Religion/Creed Sex/Gender Disability Familial Status (Pregnant or children under age 18) Retaliation
Public Accommodations (Example: Restaurant, Store, Museum, Theatre)
Race Color National Origin/Ancestry Religion/Creed Disability Sex Retaliation
Voting
Race Color National Origin Religion Disability Sex Ancestry
Do you have an attorney? Yes No
If yes, please provide the attorney's name and address:
Is any legal action pending? Yes No
List any other agencies contacted regarding your complaint:
Comments:
Statistical Information
How did you hear about our Intake Questionnaire?
Called Phoenix AG Office Called Tucson AG Office Went onto AG Website Visited an AG Satellite Office An Out of State Agency Media: Newspaper/Radio/TV Another Arizona State Agency/State Legislator Attended AG Presentation/Event Other
Declaration: By submitting this form electronically, I declare, under penalty of perjury under the laws of the state of Arizona that the information in this questionnaire is true and accurate.
Name:
Date:
Please print the following page for your records.
