Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Human Rights Online Support Request

  1. (if different from street address)

  2. Primary Phone Type*

  3. Secondary Phone Type

  4. (If different from above)

  5. Person/Agency you believe discriminated against you

  6. Primary Phone Type*

  7. Secondary Phone Type

  8. The alleged discrimination was based on:*

  9. Provide the names of any individuals with additional information regarding your complaint

  10. Witness 1

  11. Type

  12. Type

  13. Witness 2

  14. Type

  15. Type

  16. Witness 3

  17. Type

  18. Type

  19. Have you filed a complaint alleging the same discrimination with another state or federal agency?*

  20. If yes, please provide the contact information for each agency.

  21. Please attach any additional documents relevant to your complaint.

  22. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  23. Leave This Blank:

  24. This field is not part of the form submission.