You are on page 1of 9
« sCas¥B:02-cv-01026-JDW Document 18 Filed 07/02/02 Page 6 of 61 RECBPIVED PLOYM INA’ iT e mance 302 1546 eeoce25 490209 1996 1 Name. ‘Tugueneigt uiteo! (Please (First) (Last) Address. Ciy. we cany LOY rope A vac ortinh MII yo race COMCODIYA your Sex mate Fema What - and time(s) arc i available i i between 8:00 #.m.-4:30 p.m., Monda)-Friday? 1. Name and address of company/employer, labor union, employment agency or join apprenticeship/training committee cy erage swe TN op SIO OM, Teephove A= 139 voinasnnorartrones LOC. ‘What type of business is this: what product or service docs it provide? Name of Chief Exceutive OMficer (Plant Manager, cic)_{° rein TIN 00} {1 What is the most recent date of the diseriminatory action taken against you. (PLEASE GIVE SPECIFIC Dé Aug AL, 199 Feb a ,t9G i, Jnst you? Please check only those that apply. ATE: Xs) were taken ied to Hire_ Failed to Recall xed to Promote“ \AScharged_Lai-OfT_Denid Raie-arassod SZBenied Benefits/Medical Leave Failed 1o Accommodate Disability — Failed to Accommodate Religious Belict —Other (Explain) V. Do you believe that action was taken because of any one (or more) ofthe categories listed below? es ___No. Ityss. please place a check markt the lef the category. “Race Age xSex (including pregnancy) National Origin Religion __Color__Disability Other (Explain, . /Casb8:02-cv-01026-JDW Document 18 Filed 07/02/02 Page 7 of 61 PagelD 178 VI. Please provide the name of an individual ata different address who would know how lo reach you. : ‘VIL. Have you sought assistance about the action you think was discriminatory from any federal or state government a ‘es__No. I yes, who?. wy © VII. Complaint Information seg. from your union, from an aliomey, of {rom any othes Results, 1. Specify how you were discriminated against, 2. Explainas briefly and as clearly as possible what happened, who did it, where it happened. etc. 3. Why do you believe these events occurred? 4. Describe how others ofa different race, sex, age clc..were treated differently than you. 5. Were there others who were treated the same under similar circumstances? __ Yes 6. What other information do you think is relevant to this complaint? No If yes, explain Q 2 0-tle Swern and signal before me his 27 iayot_aguet 196 ‘Notary Public My Bonn. bagpicrs PEIN “Case 8102-cv-01026-JDW Document 18 Filed 07/02/02 Page 8 of 61 PagelD 179 Please list below any persons (witnesses, fellow employces, supervisors, or others) who may have Sonal information to support or clarify your complaint Please include their complete mailing address and telephone number with area code, if known, Explain what information each can provide. FORM # HR0022 (REV 3/96) RDA 1654

You might also like