DISCRIMINATION STATEMENT Page 1 of ___ I, ___________________________________, reside at ______________________ _______________________ (Name) (Street Address) in _______________________, __________________________, ___________________________________ . (City) (County) (State) (Zip) My telephone number is: Area Code ( ) ______________________ . (Number) I have been employed by: _______________________________________________ ____________________ . (Name of Employer) Located at: _______________________________________________________________________________ . (Address of Employer) Employers telephone number: Area Code ( ) _______________________ . (Numbe r) My job Classification is/was: __________________________________________ ________________________ NARRATIVE NOTE: The narrativemust describe indetail the events surrounding the actions which you claim to be discharged or discrimination in violation of A.R.S. 23-425. Therefore, you must include in your narrative the following information: (1) Craft or description of work you did, (2) The reason you believe your employer discharged you or discriminated against you, (3) The date and time the disc harge or discrimination occurred, (4) Your location where the discharge or discrimination occurred, (5) Your supervisors name, (6) The names, addresses, and phone numbers of witnesses who will substantiate your claim, (7) Adetailed description (including dates, times, locations, witnesses and persons involved) of events leading up to your discharge or discrimination, (8) Your objective in filing this discrimination compl aint, (9) Are you employed at the present time? If so, by whom? (10) A phone number where you can be contacted between 7 a.m. and 6 p.m., Monday through Friday. You may use additional paper if needed. American LegalNet, Inc. www.USCourtForms.com>>>> 2 Page ____ of ____ American LegalNet, Inc. www.USCourtForms.com>>>> 3 Page ____ of ____ I have read and had an opportunity to correct this statement consisting of ____ pages and swear that the information contained herein is true and correct to the best of my knowledge and belief. Note: I am aware that it is unlawful for me to make any false statement, representation o r certification in this document which is being fill pursuant to the Arizona Occupational Safety and Health Act of 1972 [A.R.S 23-418 (H)]. Violation of this requirement is a Class 2 misdemeanor and carries a pen alty up to $750.00. Signature of Complainant: ________________________________________ Date: ______________________ ADOSH 80 American LegalNet, Inc. www.USCourtForms.com>>>> 4 AUTHORIZATION FOR RE LEASE OF EMPLOYMENT RECORDS To Whom It May Concern: The undersigned __________________________________________, does hereby authorize The Industrial Commission of Arizona to obtain copies of any and all per sonnel and employment records involving his/her employment with ______________________________________________________ ______. Dated this ________ day of _____________________________, 20_____. ____________________________________ American LegalNet, Inc. www.USCourtForms.com