Public Accommodation

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First Name

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Primary Phone Number

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Last Name

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Secondary Phone Number

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Email Address

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Best Time to Call

Alternate Contact

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Alternate Number

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Alt Contact Best Time to Call

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Address Information

Home Address

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Unit/Apt

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City

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State

Zip

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If applicable to your complaint of discrimination, what is your:

Race

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Sexual Orientation

Color

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Gender

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Complainant

Contract

Subject

Contract Line

Origin

Case Type

Contact Information

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If applicable to your complaint of discrimination, what is your:

Incident Information

Who do you believe discriminated against you? Was it a landlord, apartment manager, owner, bank, real estate agent, broker, company or organization?

What is the nature of your complaint?

If applicable to your complaint of discrimination, what is the persons:

Public Accommodation

Contact Information

Address Information

If applicable to your complaint of discrimination, what is your:

Incident Information

Who do you believe discriminated against you? Was it a landlord, apartment manager, owner, bank, real estate agent, broker, company or organization? ​

What is the nature of your complaint?

If applicable to your complaint of discrimination, what is the persons:​

Who do you believe discriminated against you? Was it a landlord, apartment manager, owner, bank, real estate agent, broker, company or organization?

If applicable to your complaint of discrimination, what is the persons: