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BK:00027 PG <br />County of Lee Transit System <br />1615S. Third Street <br />Sanford, NC 27330 <br />Discrimination Complaint Form <br />Last Name: <br />First Name: <br />❑ Male <br />❑ Female <br />Mailing Address: <br />City: <br />State: <br />Zip: <br />Home Telephone: <br />Work Telephone: <br />E -mail Address: <br />Identify the Category of Discrimination: <br />❑ RACE ❑ COLOR ❑ NATIONAL ORIGIN ❑ AGE <br />❑ RELIGION ❑ DISABILITY ❑ SEX/GENDER ❑ INCOME STATUS <br />Identify the Race of the Complainant <br />• Black ❑ White ❑ Hispanic ❑ Asian American <br />• American Indian ❑ Alaskan Native ❑ Pacific Islander ❑ Other <br />Date and place of alleged discriminatory action(s). Please include earliest date of discrimination and most recent date of discrimination. <br />How were you discriminated against? Describe the nature of the action, decision, or conditions of the alleged discrimination. Explain as dearly <br />as possible what happened and why you believe your protected status (basis) was a factor in the discrimination. Include how other persons <br />were treated differently from you. (Attach additional page(s), if necessary) <br />The law prohibits intimidation or retaliation against anyone because he /she has either taken action, or participated in action to secure rights <br />protected by these laws. If you feel that you have been retaliated against, separate from the discrimination alleged above, please explain the <br />circumstances below. Explain what action you took which you believe was the cause for the alleged retaliation. <br />Names of individuals responsible for the discriminatory action(s): <br />15 <br />