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2. 
4. Name:
5. Telephone Number:
7. Address:
9. City:
10. State:
11. Zip:
15. Name of Person(s) That Discriminated Against You:
16. Position (if known):
18. Date of Incident:
    Date of Incident:
19. Location of Incident:
21. Address of Incident:
23. City:
24. State:
25. Zip:
29. Reason for Discrimination:

    1. Race
    2. Age
    3. Color
    4. Sex
    5. Disability
    6. National Origin
    7. Retaliation
    8. Other
30. If other, please specify:
32. Explain as briefly and clearly as possible what happened and how you were discriminated against. Indicate who was involved. Be sure to include how other persons were treated differently than you.
34. Attach any written material pertaining to your case.
38. Signature of Applicant:*
40. By checking this box I acknowledge that I am electronically signing this application to sell alcoholic beverages at a special event designated premises.*

    1. Electronic Signature
41. Date:*
    Date:
Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit Submit and Print

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