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2. First Name*
3. Last Name*
5. Today's Date and Time
   Today's Date and Time

   Today's Date and Time
6. Phone
8. Email*
10. Street Address
12. City
13. State
14. Zip
16. How should we contact you?
18. How were you discriminated against?
20. Why were you discriminated against?
22. When and where did the incident occur?
24. How were you discriminated against?
26. Why were you discriminated against?
28. When and where did the incident occur?
30. A staff member will contact you to discuss your concern and to schedule an informal conference. If you have questions, call (517) 319-6942 during normal business hours.
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