Public Accommodation Complaint Form to Florida Commission on Human Relations

fchrinfo hidden Email
example@example.com
Public Accommodation Complaint

Florida Commission on Human Relations
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
10 digit only numbersFormat: (000) 000-0000.
Alternate Phone Number
10 digit only numbersFormat: (000) 000-0000.
E-mail
Date of Birth

MMDDYYYY
Gender Identity (use up or down arrows to select)
Please provide the name of a person we can contact if we are unable to reach you.

(This information is not mandatory)
Contact Name

First NameMiddle NameLast Name
Relationship
Primary Phone Number
10 digit only numbersFormat: (000) 000-0000.
Alternate Phone Number
10 digit only numbersFormat: (000) 000-0000.
Contact Address

Street Address

Street Address Line 2

CityState

Zip Code
Contact Email
example@example.com
I believe that I was discriminated against by the following organization:
Organization Name
Address of the Organization

Street Address

Street Address Line 2

CityState

Zip Code
Organization Phone Number
10 digit only numbersFormat: (000) 000-0000.
Organization Email Address:
example@example.com
County
(or Country name if out of the states)
Type of Business
Date of Harm

MMDDYYYY
Owner name:
Owner phone number
10 digit only numbersFormat: (000) 000-0000.
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.

More options and a description box will appear after you select each discrimination type. Use up or down arrows to select options. In the description box, please describe what happened to you that you believe was discriminatory.
Race
Race - select one that applies
Race Discrimination description - Explain here

0/900
Color
Color - select one that applies

Other
Color Discrimination description - Explain here

0/900
National Origin
National Origin - select one that applies

Other
National Origin Discrimination description - Explain here

0/900
Familial Status
Familial Status
Familial Status Discrimination description - Explain here

0/900
Sex
Sex - select one that applies
Sex Discrimination description - Explain here

0/900
Sexual Orientation
Sexual Orientation related Discrimination description - Explain here

0/400
Gender Identity
Gender Identity Discrimination description - Explain here

0/400
Religion
Religion (Please identify)
Religion Discrimination description - Explain here

0/900
Disability/Handicap
Disability Discrimination description - Explain here

0/900
Please select one of the Reasons of Discrimination
Have you filed a charge previously?
Have you filed a charge previously on this matter with another agency? (use up or down arrows to select)
If so, provide the name of the agency and the date of filing:
Attorney
Are you currently represented by an attorney? (use up or down arrows to select)
Attorney Name

First NameLast Name
Attorney Address

Street Address

Street Address Line 2

CityState

Zip Code
Attorney Phone Number
10 digit only numbersFormat: (000) 000-0000.
Attorney Email
example@example.com
Acknowledge

Under penalty of perjury, I declare that I have read the foregoing complaint of discrimination and that the facts stated in it are true and correct. By submitting this complaint, I understand that the complaint of discrimination will be shared with the named business. I will advise the agency if I change my address or telephone number, and I will cooperate fully with it in the processing of my complaint in accordance with standard procedures.
Signature

You can draw or type your signature.
Acknowledge
Please, scroll up to review your information before you Sign and click "Submit", or to continue later, click "Save" button and you will get an email with the link to come back to this form.
(for Printed version) 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
Should be Empty:

Public Accommodation Complaint

Personal Information

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

I believe that I was discriminated against by the following organization:

Please select one of the Reasons of Discrimination

Have you filed a charge previously?

Attorney