Public Accommodation Intake Questionnaire

PUBLIC ACCOMMODATION INTAKE QUESTIONNAIRE

(If you file a Claim of Discrimination, your identity will be disclosed to the alleged violator)

Personal Information

Name:
Phone # :

Date of Birth:

Complete Address:
(No. & Street, City, State, Zip Code)

Contact Information (An individual who will know how to contact you at all times.)
Name:	Phone # :
Complete Address: (No. & Street, City, State, Zip Code)

Basis(es) for Discrimination

I believe that I have been Discriminated against based on one or more of the following:
(check all that apply & identify)

Race:
Color:
Sex:	Male /	Female	Pregnancy
Retaliation *

National Origin:
Disability:
Religion:

(* for protesting a prohibited housing practice or filing a previous charge of discrimination)

I believe I was discriminated against by:
(check only one box)
Realtor	Home Owner	Mortgage Company	Insurance Company
Apartment Complex	Bank / Lending Agency	Business / Establishment	Other:

Most Recent Date of Alleged Violation:
(Violation must have occurred within 365 days before today's date.)

Name:
Phone # :
Complete Address: (No. & Street, City, State, Zip Code)
Date of Appliction:
Housing / Service / Public Accommodation Applied for:
Are you currently residing at the above address? Yes No
If No, last date occupied, applied, or service requested:
Name (person spoken to):		Title:

Additional Information
Have you filed a Claim of Discrimination in the past? Yes No
Approximate Date Filed:	Whom Filed Against:
Claim # :

Briefly describe what action was taken against you that caused you to believe that you were discriminated against. Include date(s) [month/year] and name and title of the individual(s) taking action.

Witnesses [Include their home telephone # and/or address.]	Comparable(s)[Individual(s) who have committed the same violations; however, action was either less severe or not taken against them.]
What solution are you seeking to resolve your complaint?

PRIVACY ACT STATEMENT
(This form is covered by the Privacy Act of 1974; Public Law 93-579. Authorities for requesting the personal data and the uses therof are given below.)

FORM NUMBER / TITLE / DATE. CCHRC Form 2, Housing/Public Accommodation Intake Questionnaire, March 2000.
AUTHORITY. City of Corpus Christi Odinance No. 023411, as amended; Title VIII of the Civil Rights Act of 1964, as amended; and/or the Americans with Disabilities Act of 1990, 42 U.S.C 12101 et seq.
PRINCIPAL PURPOSE. The purpose of this questionaire is to solicit information to enable the Commission to awoid the intake of matters not within its juisdiction.
ROUTINE USES.Information provided on this form will be used by Commission employees to determine the evidence of facts relevant to a decision as to whether the Commission has jurisdiction over potential charges, complaints or allegations of employment discrimination. Information provided on this form may be disclosed to other state, local, and federal agencies as may be appropriate or necessary in carrying out the Commissioners' functions, including employment practice laws. Information may also be disclosed to charging parties in consideration of, or in connection with litigation.
WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND THE EFFECT ON INDIVIDUAL FOR NOT PROVIDING INFORMATION. The providing of this information is voluntary but the failure to do so may hamper the Commission's investigation of a charge of discrimination. It is not mandatory that this form be used to provide the requested information.

Pressing the submit button will send the information entered to the Corpus Christi Human Relations Commission. Please verify that all the above information is correct before submitting. There will be no preview page.
If you are not contacted in 7 days, please call (361) 826-3190