General Intake Form

Please note this is an accessible version of our interactive intake form, if you do not require advanced accessibility (screen readers, etc., please use the interactive 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. This document is also available in Arabic, French, Creole, Spanish, and Somali PDF.

*Indicates Required Fields

Your Contact Information

Email*	First Name*	Middle Initial	Last Name*
Mailing Address*	City*	State*	Zip*
County	Home Phone (207-123-4567)	Cell Phone (example: 207-123-4567)	Work Phone (example: 207-123-4567)

Related Contact

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

Name	Relationship	Telephone Number (207-123-4567)
Mailing Address	City	State	Zip	County

Discrimination Details

Complaint Against

I Wish to File a Complaint Against: *	Employer Union Employment Agency Other If other please specify:
Name of Organization *	Person to Contact	Title or Position (i.e. Owner/President/H.R. Mgr.)	Telephone Number (207-123-4567)
Mailing Address *	City *	State *	Zip *
Physical Address (if different):

If Complaint Regards Employment Discrimination:

Approximate # of people employed by Company or members of Union?	Are you employed by this company at this time?
If you are currently employed
When did you first become employed?	Present position?
If you were previously employed
Previous position	Date left position (01/01/2014)	Reason for leaving (laid off, terminated, quit, etc.)
If you were never employed
Position I applied for	Date applied (01/01/2014)

Have You Ever Filed a Complaint With This Office?	If yes, complete the following: 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.

(Rev. 01/22)

I Believe I Have Been Discriminated Against In: *	Employment Access to Public Accommodation Extension of Credit Education
Because of: *	Age (Employment, PA, & Credit Cases Only) Specify date of birth: (mm/dd/yy) Children (Lodging Only-except certain B&B establishments) Familial Status (Employment & Housing Only) Genetic Predisposition Marital Status (Credit Only) National Origin/Ancestry ( Specify: ) Physical/Mental Disability ( Specify: ) Race/Color ( Specify: ) Receipt of a permanent prot. from abuse Order: ) Religion ( Specify: ) Retaliation ( Specify: ) Sex (This includes sexual harassment) Sexual Orientation Whistleblower Retaliation (Employment Only) Workers' Compensation Retaliation (Employment Only)
I Was Denied the Same Opportunity or Treated Differently From Others In (Please check all applicable.) *	Hiring Dismissal Benefits Pay Promotion Working Conditions Loan Credit Sale Rental Other: If other, describe briefly:
What Was the Most Recent Date of Alleged Discrimination? * (01/01/2014)
What Reason Was Given for This Adverse Action? *

Maine.gov

Maine Human Rights Commission