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2. Complainant Information
4. First Name*
5. Last Name*
7. Address1*
9. Address2
11. City*
12. State*
13. Zip*
15. Phone number*
19. Complainant Representative
21. First Name
22. Last Name
24. Address1
26. Address2
28. City
29. State
30. Zip
32. Phone number
33. Relationship (e.g. friend, attorney, parent, etc.)
37. Name of agency, institution, or department whom you allege discriminated against you:
39. Address of agency, institution, or department whom you allege discriminated against you:
41. Address1
43. Address2
45. City
46. State
47. Zip
49. Name of individual(s) whom you allege discriminated against you (if known):
51. Discrimination because of:

    1. Race
    2. Sex
    3. Income Status
    4. Color
    5. Age
    6. Religion

    1. National Origin
    2. Handicap/Disability
    3. Retaliation
    4. Family
    5. Other
53. Please list the name(s) and phone number(s) of any person, if known, that the City of Cocoa could contact for additional information to support or clarify your allegation(s).*
55. Please explain as clearly as possible how, why, when and where you believe you were discriminated against. Include as much background information as possible about the alleged acts of discrimination. *
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57. 1. Receive an email copy of this form.
58. Email address

    This field is not part of the form submission.

59. Submit

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