Washington Lawyers' Committee for Civil Rights and Urban Affairs

INTAKE QUESTIONNAIRE

Washington Lawyers' Committee for Civil Rights and Urban Affairs
11 Dupont Circle NW, Suite 400
Washington DC 20036
Fax 202-319-1010

You may fill out this questionnaire on line; when you have completed it, press the Submit button. Or you may print the form ([Word document] [PDF file]), fill it out (type or print legibly) and mail or fax it to the Committee. All questionnaires will be treated confidentially. We will not share or sell information about you. We will only use your e-mail address to respond to you directly.

This form is for use by the Washington Lawyers' Committee to evaluate your request for assistance. It does not mean that we have agreed to represent you. You are still responsible for any filing deadlines.

Please understand that the Washington Lawyers’ Committee receives many requests for assistance each day. Therefore, it may take one to two weeks for someone from our organization to respond to your request. We appreciate your patience...

PERSONAL INFORMATION

Name
Street Address, Apt #
City
State, Zip Code
Telephone #
Home	Work	Cellular
E-Mail Address

DISCRIMINATION

Do you believe that you have suffered illegal discrimination in any of the following:

Housing		Employment
Governmental Services		As a customer of a business (Public Accommodation)
		(specify which business)
Other (specify)

Category of Discrimination (check any that apply)
Race		Sex
Religion		Immigration Status
National Origin		Pregnancy
Age		Sexual Harassment
Sexual Orientation		Disability
		(identify)
Other (Specify)

Name and Address of Discriminating Company, Agency, Organization, or Person

Name
Street Address (If known)
City, State, Zip
Briefly describe the events you believe were discriminatory:
Date of discrimination (or last discriminatory act)
What steps have you already taken to resolve the matter? (For example, have you filed any charges or claims with any agency, organization, or court?
If there is special urgency, please explain

ASYLUM

Are you considering applying for political asylum?
If so, from what country?
When did you arrive in the United States?
Do you believe that you will be persecuted if you return to that country on account of:
Political Opinion		Social Group
Religion		Race
Nationality
Briefly describe why you believe that you would be persecuted: