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2. Did the alleged discrimination occur in New Hanover County?*

   1. Yes
   2. No
4. Our staff will not consider any complaint concerning any matters for which the complainant has already filed complaints with the EEOC, North Carolina Human Relations Commission or any other agency or institution. Have you filed a complaint with any other business, organization, court or governmental organization?*

   1. Yes
   2. No
6. First Name*
7. Last Name*
8. Email*
10. Street Address
11. Address Line 2
12. Phone
14. City
15. State
16. ZIP Code
18. If needed, the name of a person who knows where to contact you:
19. Contact's Email
21. Contact's Phone
22. Contact's Street Address
23. Contact's Address Line 2
25. Contact's City
26. State
27. ZIP Code
31. Name of the person or entity you are charging with discrimination:*
32. Phone
34. Street Address
35. Address Line 2
37. City
38. State
39. ZIP Code
41. The alleged discrimination occurred in:*

    1. Education
    2. Employment
    3. Healthcare
    4. Housing
    5. Public Administration
    6. Other
42. Cause of the alleged discrimination:*

    1. Age
    2. Creed/Religion
    3. Disability
    4. Gender
    5. National Origin
    6. Race
    7. Sexual Orientation
44. Please Describe Your Complaint*

    Please explain your reasons for filing your complaint and why you believe you were discriminated against. Please be as specific as possible.

46. Confirmation*

    1. I affirm that this complaint is true to the best of my knowledge and information.
Leave This Blank:


48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit

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