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4. Harford County Human Relations Complaint Form
   Under provision of the Harford County Charter 95 (Discriminatory Practices)
6. COMPLAINANT INFORMATION
8. First Name
9. Last Name
11. Occupation/Organization
13. Phone Number
14. Email Address
16. Address
18. City
19. State
20. Zip Code
22. Mailing Address
24. City
25. State
26. Zip Code
28. RESPONDENT INFORMATION
30. First Name
31. Last Name
33. Occupation/Organization
35. Phone Number
36. Email Address
38. Address
40. City
41. State
42. Zip Code
44. Mailing Address
46. City
47. State
48. Zip Code
50. ALLEGED DISCRIMINATORY INCIDENT
52. Basis for Discrimination

    (Please check all that apply)

    1. Race
    2. Creed
    3. Color
    4. Sex
    5. National Origin
    6. Age
    7. Occupation

    1. Marital Status
    2. Familial Status
    3. Political Opinion
    4. Personal Appearance
    5. Mental Handicap
    6. Physical Handicap
54. Discriminatory of Wrongful Practice Involving:

    (Please check all that apply)

    1. Administration of Justice
    2. Education
    3. Employment
    4. Governmental Services

    1. Housing
    2. Public Accommodations
    3. Other
56. If other, please specify
58. Date & Time of Incident
    Date & Time of Incident

    Date & Time of Incident
60. Please give the name, address and telephone number of any other agency you contacted about this complaint.
62. Name of Agency
64. Address
66. City
67. State
68. Zip Code
70. Phone Number
71. Email Address
73. How did you hear about the Office of Human Relations?
75. Did anyone witness the events you described above? If yes, please list their contact information, if possible.

    1. Yes

    1. No
77. First Name
78. Last Name
80. Address
82. City
83. State
84. Zip Code
86. Phone Number
88. Describe what happened
90. Parties to complaints may voluntarily resolve their differences without an extensive investigation or expenditure of resources by participating in a mediation process. Are you interested in participating in such a process?

    1. Yes

    1. No
92. By submitting this form, I do hereby attest that the information in the foregoing complaint is true and correct to the best of my knowledge.
Leave This Blank:


94. 1. Receive an email copy of this form.
95. Email address

    This field is not part of the form submission.

96. Submit

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