#51 State House Station Augusta, ME 04333 | Phone: 207.624.6290 | Fax: 207.624.8729 | Maine Relay 711 | Visitor Information

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General Intake Form

(For Housing Cases Use Housing Intake Questionnaire)

Note that required fields are marked with an asterisk. The form cannot be submitted unless all required fields are filled in. You may also download a printable PDF file of this form for mail submission. This file requires the free Adobe Reader.

Your Contact Information

Name: (First) * (Middle Initial) (Last) *

Street Address *

City *

State *

Zip *

County *

Home Phone

Cell Phone

Work Phone

Email Address

Related Contact

Name of a relative, friend or neighbor in the local area who would know how to reach you.

Name

Relationship

Telephone Number

Street Address

City

State

Zip

County

Discrimination Details

I Believe I Have Been Discriminated Against In: *

Employment

Access to Public Accommodation

Extension of Credit

Education

Because of: *

Race/Color (Specify: )

National Origin/Ancestry (Specify: )

Sex (This includes sexual harassment)

Sexual Orientation

Religion (Specify: )

Workers' Compensation Retaliation (Employment Only)

Whistleblower Retaliation (Employment Only)

Age (Employment & Credit Cases Only] (Specify date of birth: (mm-dd-yyyy)

Genetic Predisposition

Children (Lodging Only-except certain B&B establishments)

Marital Status (Credit Only)

Physical/Mental Disability

If other, describe briefly:

What Was the Most Recent Date of Alleged Discrimination? *

What Reason Was Given for This Adverse Action? *

Complaint Against

I Wish to File a Complaint Against: *
Employer
Union
Employment Agency
Other

If other please specify:

Name of Organization *

Telephone Number

Person to Contact

Title or Position (i.e. Owner/President/H.R. Mgr.)

Mailing Address

Street Address *

City *

State *

Zip *

Physical Address (if different):

If Complaint Regards Employment

Approximate number persons employed by Company or members of Union?

Are you employed by this company at this time?

Currently Employed

When did you first become employed?

Present position?

Previously Employed

Previous position

Date left position

Reason for leaving (laid off, terminated, quit, etc.)

Never employed

Position I applied for

Date applied

Have You Ever Filed a Complaint With This Office? If yes, answer below.

Against Whom?

Approximately when?

Do you have an attorney?

Attorney's Name

Detail

Is there a union at your place of employment? If so, have you brought this matter to their attention?

To assist us in understanding the details of your situation, please provide a brief description of the reasons you believe you have been discriminated against.

Give Details, Include Names and Dates, Etc.

If content on this page is inaccessible and you would like to request the information in a different format or language, please contact us at (207) 624-6290. If you are having difficulties with viewing our website please contact our webmaster at 624-6299.

Credits

Information

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Maine Human Rights Commission

#51 State House Station Augusta, ME 04333 | Phone: 207.624.6290 | Fax: 207.624.8729 | Maine Relay 711 | Visitor Information

General Intake Form

If content on this page is inaccessible and you would like to request the information in a different format or language, please contact us at (207) 624-6290. If you are having difficulties with viewing our website please contact our webmaster at 624-6299.

Credits

Information