Please describe what you would like to see done to correct the situation.

Please describe the incident(s) as clearly and concisely as possible. Provide as much detail as you can recall, including when and where the events occurred and who said what to whom. Explain why you believe the conduct or treatment was discriminatory. Use additional pages, if necessary.

Name: ___ Phone: ___ Name: ___ Phone: ___

numbers of any witnesses to the incident(s). Use additional pages, if necessary.