Pre-Interview Information Form

The Metropolitan Human Relations Commission

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The alleged discrimination occurred in*

Full Name (including middle initial)*

Permanent Address*

City*

State*

Zip Code*

Phone*

Work Phone*

Cell Phone*

Email*

Date of Birth*

Please provide the name of someone not living in your home who knows where you are at anytime*

Phone*

Address*

City*

State*

Zip Code*

Relationship*

PLEASE PROVIDE the REASON for the difference in treatment: (check all that apply)* Race or Color National Origin Ancestry Place of Birth Religion Age Disability Pregnancy Equal Pay Issue Sex Retaliation Familial Status(Housing only) Sexual Orientation Sexual Harassment

Date of Incident/Discrimination*

I learned about this agency by*

If you are charging an Employer with discrimination, are you currently employed with them?

If charging a Housing Provider with discrimination, are you facing eviction?

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Laws

Title VII of the Civil Rights Act of 1964
Metro's Rules & Regulations
Fair Housing Act
Equal Pay Act of 1963
Civil Rights Act of 1991
Fort Wayne City Ordinance
Age Discrimination in Employment Act of 1967
Americans with Disabilities Act Amendments Act 2008

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