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CHARGE OF DISCRIMINATION |
AGENCY |
CHARGE NUMBER |
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This form is affected by the Privacy Act of 1974; See
Privacy act statement before completing this form. |
[ ] FEPA
[x] EEOC |
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__________________________________ and EEOC
State or local Agency,
if any
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NAME (Indicate Mr.. Ms., Mrs.)
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HOME TELEPHONE (Include Area Code) |
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STREET ADDRESS
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CITY. STATE AND ZIP CODE
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DATE OF BIRTH |
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NAMED IS THE EMPLOYER, LABOR ORGANIZATION, EMPLOYMENT
AGENCY, APPRENTICESHIP COMMITTEE, STATE OR LOCAL GOVERNMENT AGENCY WHO
DISCRIMINATED AGAINST ME (If more than one list below). |
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NAME
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NUMBER OF EMPLOYEES, MEMBERS
+15 |
TELEPHONE (Include Area Code):
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STREET ADDRESS
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CITY. STATE AND ZIP CODE
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COUNTY
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NAME |
NUMBER OF EMPLOYEES, MEMBERS: |
TELEPHONE (Include Area Code) |
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STREET ADDRESS |
CITY. STATE AND ZIP CODE
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COUNTY |
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CAUSE OF DISCRIMINATION BASED ON (Check appropriate
box (es) |
DATE DISCRIMINATION TOOK PLACE |
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[] RACE |
[] COLOR |
[] SEX |
[] RELIGION |
[] NATIONAL ORIGIN |
EARLIEST (ADEAJEPA)
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LATEST (ALL)
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RETALIATION |
[] AGE |
[] DISABILITY |
[] OTHER Pregnancy Act |
[] CONTINUING ACTION
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THE PARTICULARS ARE (If additional space is needed.
al/ach extra sheet(s)
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[x] I want this charge filed with both the EEOC and the
State or local Agency, if any. I will advise the agencies if I change my
address or telephone Number and I will cooperate fully with them in the
processing of my charge in accordance with their procedures. |
State of Virginia
City of Richmond to wit:
I swear or affirm that I have read the above charge and
that it is true to the best of my knowledge, information and belief.
/x/_______________________________________________
_________
SIGNATURE OF COMPLAINANT DATE
Sworn to and subscribed to before the undersigned notary
public in and for said jurisdiction this ____ day of _______________,
200_____.
My commission expires: / /
_____________________________________________________
Notary Public |
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I declare under penalty of perjury that the foregoing is
true and correct. |
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Date:_____ Charging Party :_______________________ |
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EEOC Form 5 modified
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