* * * EMPLOYMENT * * * COMPLAINT OF DISCRIMINATION UNDER THE PROVISIONS OF THE CALIFORNIA FAIR EMPLOYMENT AND HOUSING ACT DFEH # DFEH USE ONLY CALIFORNIA DEPARTMENT OF FAIR EMPLOYMENT AND HOUSING YOUR NAME (indicate Mr. or Ms.) TELEPHONE NUMBER (INCLUDE AREA CODE) ADDRESS CITY/STATE/ZIP COUNTY COUNTY CODE NAMED IS THE EMPLOYER, PERSON, LABOR ORGANIZATION, EMPLOYMENT AGENCY, APPRENTICESHIP COMMITTEE, OR STATE OR LOCAL GOVERNMENT AGENCY WHO DISCRIMINATED AGAINST ME: NAME TELEPHONE NUMBER (Include Area Code) ADDRESS │ │ CITY/STATE/ZIP COUNTY NO. OF EMPLOYEES/MEMBERS (if known) DATE MOST RECENT OR CONTINUING DISCRIMINATION TOOK PLACE (month, day, and year) DFEH USE ONLY │ COUNTY CODE │ │RESPONDENT CODE │ THE PARTICULARS ARE: I allege that on following conduct occurred: _____ termination _____ lay-off _____ demotion _____ harassment _____ genetic characteristics testing _____ constructive discharge (forced to quit) _____ impermissible non-job-related inquiry , the _____ denial of employment _____ denial of family or medical leave _____ denial of promotion _____ denial of pregnancy leave _____ denial of transfer _____ denial of equal pay _____ denial of accommodation _____ denial of right to wear pants _____ failure to prevent discrimination or retaliation _____ denial of pregnancy accommodation _____ retaliation _____ other (specify) ____________________________________________ by Name of Person Job Title (supervisor/manager/personnel director/etc.) _____ sex _____ national origin/ancestry _____ disability (physical or mental) _____ age _____ marital status _____ medical condition (cancer _____ religion _____ sexual orientation _____ race/color because of: _____ association or genetic characteristic) _____ retaliation for engaging in protected activity or requesting a protected leave or accommodation _____ other (specify) ______________________________________________________ State what you believe to be the reason(s) for discrimination I wish to pursue this matter in court. I hereby request that the Department of Fair Employment and Housing provide a right-to-sue notice. I understand that if I want a federal notice of right-to-sue, I must visit the U.S. Equal Employment Opportunity Commission (EEOC) to file a complaint within 30 days of receipt of the DFEH "Notice of Case Closure," or within 300 days of the alleged discriminatory act, whichever is earlier. I have not been coerced into making this request, nor do I make it based on fear of retaliation if I do not do so. I understand it is the Department of Fair Employment and Housing's policy to not process or reopen a complaint once the complaint has been closed on the basis of "Complainant Elected Court Action." I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct of my own knowledge except as to matters stated on my information and belief, and as to those matters I believe it to be true. Dated COMPLAINANT'S SIGNATURE At City DATE FILED: DFEH-300-03 (04/08) DEPARTMENT OF FAIR EMPLOYMENT AND HOUSING STATE OF CALIFORNIA American LegalNet, Inc. www.FormsWorkflow.com RIGHT-TO-SUE COMPLAINT INFORMATION SHEET DFEH needs a separate signed complaint for each employer, person, labor organization, employment agency, apprenticeship committee, state or local government agency you wish to file against. If you are filing against both a company and an individual(s), please complete separate complaint forms naming the company or an individual in the appropriate area. Please complete the following so that DFEH can process your complaint and for DFEH for statistical purposes, and return with your signed complaint(s): YOUR GENDER: __ Female __ Male YOUR RACE:/ETHNICITY (Check one) YOUR OCCUPATION: __ African-American __ Clerical __ African - Other __ Craft __ Asian/Pacific Islander (specify)___________ __ Equipment Operator __ Caucasian (Non-Hispanic) __ Laborer __ Native American __ Manager __ Hispanic(specify)____________________ __ Paraprofessional YOUR PRIMARY LANGUAGE (specify) __ Professional _______________________________________ __ Sales __ Service YOUR AGE: __ __ __ Supervisor __ Technician IF FILING BECAUSE OF YOUR NATIONAL ORIGIN/ANCESTRY, YOUR NATIONAL ORIGIN/ANCESTRY (specify) HOW YOU HEARD ABOUT DFEH: __ Attorney _______________________________________ IF FILING BECAUSE OF DISABILITY, __ Bus/BART Advertisement YOUR DISABILITY: __ Community Organization __ AIDS __ EEOC __ Blood/Circulation __ EDD __ Brain/Nerves/Muscles __ Friend __ Digestive/Urinary/Reproduction __ Human Relations Commission __ Hearing __ Labor Standards Enforcement __ Heart __ Local Government Agency __ Limbs (Arms/Legs) __ Poster __ Mental __ Prior Contact with DFEH __ Sight __ Radio __ Speech/Respiratory __ Telephone Book __ Spinal/Back __ TV __ DFEH Web Site IF FILING BECAUSE OF MARITAL STATUS, YOUR MARITAL STATUS: (Check one) DO YOU HAVE AN ATTORNEY WHO HAS AGREED TO __ Cohabitation REPRESENT YOU ON YOUR EMPLOYMENT DISCRIMINATION CLAIMS IN COURT? IF YOU CHECK “YES”, YOU WILL BE __ Divorced RESPONSIBLE FOR HAVING YOUR ATTORNEY SERVE THIS __ Married DFEH COMPLAINT. __ Single IF FILING BECAUSE OF RELIGION, YOUR RELIGION: (specify) ____________________________________ __ Yes __ No PLEASE PROVIDE YOUR ATTORNEY’S NAME, ADDRESS AND PHONE NUMBER: IF FILING BECAUSE OF SEX, THE REASON: __ Harassment __ Orientation __ Pregnancy __ Denied Right to Wear Pants __ Other Allegations (List) ________________________ _______________________________________ DFEH-300-03-1 (04/08) Department of Fair Employment and Housing State of California _______________________________________ Your Signature Date _______________________________________ American LegalNet, Inc. www.FormsWorkflow.com