2. Bismarck Human Relations Committee Comment/Complaint Form
4. The purpose of this form is to assist you in filing a discrimination complaint with the Bismarck Human Relations Committee. You are not required to fill out this form. Any information provided is open to public record.
6. Name:
8. Name of person discriminated against (if different from you):
10. Address:
11. Phone Number:
13. City:
14. State:
15. Zip:
17. Email:
19. The allegation of discrimination was because of:

    1. Age
    2. Color
    3. Credit
    4. Disability
    5. Education

    1. Employment
    2. Gender
    3. Hate Crime
    4. Housing
    5. Marital Status

    1. National Origin
    2. Pregnancy
    3. Presence of Children
    4. Public Accommodation
    5. Race

    1. Receipt of Public Assistance
    2. Religion
    3. Sexual Orientation
    4. Other

    Check all that apply
21. Name of the organization / group / entity that discriminated:
23. Name of individual(s) (if known):
25. When did the discrimination take place?
27. Please explain as clearly as possible how you were discriminated against, why you believe it happened and who was involved.
29. What remedy are you seeking for alleged discrimination?
31. Please upload any additional information or documents:
33. Signature:*
34. Date:*
    Date:
36. By checking this box I acknowledge that I am electronically signing this form and any information provided is open to public record.*

    1. Electronic Signature
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit Submit and Print

* indicates a required field