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?

Would you like an interpreter?

Yes

No

If Yes, what language?

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