HUMAN RIGHTS BUREAU DISCRIMINATION INQUIRY FORM
Personal Information
Indicates the fields required in the form and cannot be left blank.
Last Name
First Name
Middle Initial
Mailing Address Line 1
Mailing Address Line 2
City
State
Select One
New Mexico
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
County
Select One
Bernalillo
Catron
Chaves
Cibola
Colfax
Curry
De Baca
Dona Ana
Eddy
Grant
Guadalupe
Harding
Hidalgo
Lea
Lincoln
Los Alamos
Luna
McKinley
Mora
Otero
Quay
Rio Arriba
Roosevelt
Sandoval
San Juan
San Miguel
Santa Fe
Sierra
Socorro
Taos
Torrance
Union
Valencia
Multi-establishment
Statewide
Foreign locations
Out-of-state locations
Unknown locations
Phone
Secondary Phone
Email
Contact Preference
Select One
Email
Phone
No Preference
Gender
Select One
Male
Female
Other
Year of Birth
Preferred Language
Select One
English
Spanish
Afrikaans
Albanian
American Sign Language
Amharic
Arabic
Armenian
Bengali
Bosnian
Bulgarian
Burmese
Cambodian
Changhainese
Chinese - Cantonese
Chinese - Mandarin
Croatian
Czechoslovakian
Danish
Dari
Dutch
Dutch/Flemish
Egyptian
Estonian
Farsi
Farsi/Afghani/Dari
French
German
Greek
Gujurati
Haitian Creole
Hebrew
Hindi
Hmong
Hungarian
Indonesian
Iranian/Farsi/Persi
Italian
Japanese
Keresan
Khmer
Korean
Laotian
Lebanese
Malay
Navajo
Pakistani
Palau
Papiamento
Persian
Polish
Portuguese
Punjabi
Romanian
Russian
Samoan
Serbian
Serbo-Croatian
Shanghai
Somali
Swahili
Tagalog
Taiwanese
Tamil
Tewa
Thai
Tibetan
Tigrinya
Tiwa
Toisanese
Toishan
Tongan
Towa
Trigina
Turkish
Twi
Ukrainian
Urdu
Vietnamese
Wolog
Xanganese
Yiddish
Yoruba
Organization’s Information (involved in the alleged illegal action(s))
Company/Agency Name
Number of Employees
Type of Business
Select One
Architecture and Engineering
Arts, Design, Entertainment, Sports, and Media
Building and Grounds Cleaning and Maintenance
Business and Financial Operations
Community and Social Services
Computer and Mathematical
Construction and Extraction
Education, Training, and Library
Farming, Fishing, and Forestry
Food Preparation and Serving Related
Healthcare Practitioners and Technical
Healthcare Support
Installation, Maintenance, and Repair
Legal
Life, Physical, and Social Science
Management
Military Specific Occupations
Office and Administrative Support
Personal Care and Service
Production
Protective Service
Sales and Related
Transportation and Material Moving
Mailing Address Line 1
Mailing Address Line 2
City
State
Select One
New Mexico
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
County
Select One
Bernalillo
Catron
Chaves
Cibola
Colfax
Curry
De Baca
Dona Ana
Eddy
Grant
Guadalupe
Harding
Hidalgo
Lea
Lincoln
Los Alamos
Luna
McKinley
Mora
Otero
Quay
Rio Arriba
Roosevelt
Sandoval
San Juan
San Miguel
Santa Fe
Sierra
Socorro
Taos
Torrance
Union
Valencia
Multi-establishment
Statewide
Foreign locations
Out-of-state locations
Unknown locations
Address where alleged illegal action(s) occurred (if not same as mailing address):
Same as the above organization address?
Alleged Address Line 1
Alleged Address Line 2
City
State
Select One
New Mexico
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
County
Select One
Bernalillo
Catron
Chaves
Cibola
Colfax
Curry
De Baca
Dona Ana
Eddy
Grant
Guadalupe
Harding
Hidalgo
Lea
Lincoln
Los Alamos
Luna
McKinley
Mora
Otero
Quay
Rio Arriba
Roosevelt
Sandoval
San Juan
San Miguel
Santa Fe
Sierra
Socorro
Taos
Torrance
Union
Valencia
Multi-establishment
Statewide
Foreign locations
Out-of-state locations
Unknown locations
Phone
Secondary Phone
Alleged Violation(s)
Type of Violation Alleged. Check all that apply.
Employment
Housing
Credit
Public Accommodation
Are you raising an issue about being paid less than the opposite sex for equal work?
Select One
Yes
No
Are you raising an issue about being asked about your arrests or convictions on an employment application?
Select One
Yes
No
Are you raising an issue about being discriminated against for engaging in legal activity related to the use of medical cannabis?
Select One
Yes
No
You Are Alleging Discrimination, What Is the Reason(Basis) For Your Claim? Check all that apply.
For example, if you feel that you were treated differently than someone else because of your race, you should check the box next to “Race.” If you feel that you were treated differently for more than one reason, check all that apply.
Color
Race
National Origin
Ancestry
Age (40+years)
Sex
Pregnancy, Childbirth,or Related Medical Condition
Sexual Orientation
Gender
Gender Identity
Spousal Affiliation
Religion
Disability
Serious Medical Condition
Paid Less than the Opposite Sex for Equal Work
Conviction/Arrest History on Employment Application
Activity Related to Medical Cannabis Use
Are you alleging you were retaliated against?
Select One
Yes
No
Employment Information
Your Job Title
Date of Hire
Date Employment Ended
(if applicable):
Reason Employment Ended
Select One
Terminated
Voluntarily Left
Laid Off
Other
Are/Were you an Independent Contractor?
Select One
Yes
No
Duration of Alleged Violation
When did the alleged violation(s) begin?
What is the most recent date of an alleged discriminatory or illegal action?
Urgent Medical Condition
Do you have a medical condition that poses a serious threat to your life within the next year?
Select One
Yes
No
Individual(s) Whom You Allege Acted Illegally
Complete this section only if you would like to name an individual in your complaint.
Do you wish to name an individual in your complaint?
Select One
Yes
No
If Yes, provide the individual(s) information.
Last Name
First Name
Phone
City of Residence
Job Title
Is or was this person your employment supervisor
Select One
Yes
No
Would you like to name another individual?
Select One
Yes
No
Last Name
First Name
Phone
City of Residence
Job Title
Is or was this person your employment supervisor
Select One
Yes
No
Would you like to name another individual?
Select One
Yes
No
Last Name
First Name
Phone
City of Residence
Job Title
Is or was this person your employment supervisor
Select One
Yes
No
Filings
Did you file a charge in this matter with U.S. Equal Employment Opportunity Commission (EEOC)?
Select One
Yes
No
Do you currently have legal representation in this matter?
Select One
Yes
No
Allegations Details
What happened to you that you believe is against the law?
Please Explain: