Form Erd-10241 - Discrimination Complaint Public Accommodation Or Amusement 2007
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1
2
3
4To be completed
State of Wisconsin
Department of workforce Development
by ERD.
Discrimination Complaint
Equal Rights Division
ERD Case #
Civil Rights Bureau
Public Accommodation or Amusement
CR
For Office Use
Important!! Please Read All Of The Instructions On Page 3 Before Starting. Type Or
Print In Black Ink.
Personal information you provide may be used for secondary purposes. [Privacy Law, s. 15.04(1)(m)
Wisconsin Statutes]
1. Complainant Information
2. Respondent Information
Last Name
First Name
Initial
Respondent name
Street Address
City
State
Zip Code
Street Address
Home Telephone Number
City
State
Zip Code
(
)
Work Telephone Number
Respondent Telephone Number
(
)
(
)
3. Your complaint may be filed with another agency unless you check “no” below.
Yes
See #3, in the instructions page, for more details.
No
4. County in which the discrimination occurred?
Name of County:_______________________
5. BASIS: You must list a basis for your complaint. (For example: “sex-female”, “race-African
American”, “disability-visual impairment”, “sexual orientation-homosexual”.
(See page three for
complete listing of bases).
What is the basis for your complaint? ______________________________________________________
_____________________________________________________________________________________
Please go on to the next page
ERD-10241 (R. 1/2007)
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