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For all civil rights or discrimination concerns, please complete the following questionnaire. When completed, click on the Submit button.

Or, you may download a pdf of this form, fill it out (please type or print legibly) and mail, email 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 email 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 inquiry. We appreciate your patience.

Personal Information (*indicates a required field)
First name*
Last name*
Address line 1*
Address line 2
City*
State*
Zip*
Email*
 
Phone Numbers
Daytime
Evening
Cell
 
Discrimination/Civil Rights Violation
Do you believe that you have been a victim of any of the following unlawful activities (select one):
Employment discrimination
Unpaid wages/overtime wages
Housing discrimination
Discrimination in government services
Discrimination as a customer of a business
(public accommodations)
Police misconduct
Hate crimes
Discrimination in lending and/or insurance concerns
Other (specify)
Category of Discrimination (check all that apply)
Race Sexual harassment
Religion Immigration status
Sex National origin
Sexual Orientation Age
Gender Identity Pregnancy
Disability (identify)
Other (specify)
 
Discriminating company, agency, organization or individual
Name
Street address (if known)
City
State
Zip
Briefly describe the events you believe were discriminatory



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