GBA-F: Report of Discrimination

Name of Complainant: _________________________________________________________________________

For Employees, Position: _______________________________________________________________________

For Applicants, Position Applied For: ______________________________________________________________

Address, Phone Number, and Email Address:

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Date(s) of Alleged Discrimination: ________________________________________________________________

Name of person(s) you believe discriminated against you or others:

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Please describe in detail the incident(s) of alleged discrimination, including where and when the incident(s) occurred. Please name any witnesses who may have observed the incident(s). Please include a description of any past incidents that may be related to this complaint. Attach additional pages if necessary.

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I certify that the information provided in this report is true, correct and complete to the best of my knowledge.

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Signature of ComplainantDate
Complaint Received By:_____________________________________________________
 Compliance OfficerDate

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