TAQ Public Accommodation Form to Florida Commission on Human Relations

FCHR Public Accommodation Technical Assistance Questionnaire
1. Personal Information
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
County*
(or Country name if out of the states)
Primary Phone Number*

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
E-mail
Date of Birth*

MonthDayYear
Date
Gender Identity*

FemaleMaleNon-BinaryOther
2. Please provide the name of a person we can contact if we are unable to reach you
Contact Name*

First NameMiddle NameLast Name
Relationship*
Contact Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone Number*

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
3. I believe that I was discriminated against by the following organization(s):
Organization Name
Address of the Organization

Street Address

Street Address Line 2

CityState

Zip Code
County
(or Country name if out of the states)
Organization's Phone Number

Area CodePhone Number
Type of Business
Owner Name
Owner phone number

Area CodePhone Number
4. Organization Representative Contact Information (If known)
Representative Name:

First NameMiddle NameLast Name
Representative Address

Street Address

Street Address Line 2

CityState

Zip Code
County
(or Country name if out of the states)
Owner phone number

Area CodePhone Number
Representative Alternate Phone Number

Area CodePhone Number
Representative Email Address
example@example.com
5. What is the reason (basis) for your claim of public accommodation discrimination? FOR EXAMPLE, if you feel that you were treated worse than someone else because of race, you should check the box next to Race. If you feel you were treated worse for several reasons, such as your sex, religion and national origin, check all that apply.
Race

BlackWhiteAsianNative Hawaiian/Pacific IslanderAmerican Indian or Alaska Native
Color

Light ComplexionDark ComplexionOther
National Origin

HispanicMexicanArab/Afghan/Middle EasternEast indianOther
Sex

FemaleMale
Familial Status

PregnantChild under 18 years of age
Sexual Orientation

Yes
Gender Identity

Yes
Retaliaton

Yes
Religion (Please identify)
Disability/Handicap

Yes
6. What happened
What happened to you that you believe was discriminatory? Include the date(s) of harm, the action(s), and the name(s) and title(s) of the person(s) who you believe discriminated against you. Please fax or email additional pages if needed. (Example: 08/08/2011 – Refused service by Mr. John Smith, waiter) - Explain here*
7. Have you filed a charge previously?
Have you filed a charge previously on this matter with another agency?*

YesNo
If so, provide the name of the agency and the date of filing:
8. Attorney
Are you currently represented by an attorney?*

YesNo
If yes, please provide name, address, telephone number and email address

0/160
Mail or Fax to:

Florida Commission on Human Relations
4075 Esplanade Way, Room 110
Tallahassee, Florida 32399-7020
Telephone (850) 488-7082
Facsimile (850) 487-1007
Please, scroll up to review your information before you click "Submit", or to continue later, click "Save" button and you will get an email with the link to come back to this form.
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FCHR Public Accommodation Technical Assistance Questionnaire

1. Personal Information

2. Please provide the name of a person we can contact if we are unable to reach you

3. I believe that I was discriminated against by the following organization(s):

4. Organization Representative Contact Information (If known)

6. What happened

7. Have you filed a charge previously?

8. Attorney