EmailMe Form - File A Complaint

1. Who is making this complaint?

This information will only be submitted to the Civil Rights Department.

Name *

First Last

Email *

Ethnic Background

Religion

Gender *

Male

Female

Primary #

### - ### - ####

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

2. My complaint is against the following:

(If more than one person or agency, provide additional information on a separate sheet.)

Government Agency/Company

Name

First Last

Email

Web Site

Home #

### - ### - ####

Cell #

### - ### - ####

Gender

Male

Female

Work #

### - ### - ####

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

3. Details of Incident

Please Provide a Detailed Description of the Incident *

4. Attach a complete description of the incident that you are reporting. State clearly what you would like the CAIR-STL to do for you.

By submitting a request for legal help to the Civil Rights Department of CAIR-MO, you acknowledge the following:

The information I have given is accurate and complete to the best of my knowledge and belief. I understand that by receiving and considering this request for assistance, the Civil Rights Department of CAIR is not representing me and not responsible for ensuring that any statute of limitations or notices requirements are met in my case. I understand that the information is being submitted to the Civil Rights Department. Once you have submitted your information, please wait at least 3 business days before contacting us if you have not heard back from us. We receive a high volume of requests for assistance and may take some time to respond.

Add me to CAIR-MO Mailing List *

Yes

No

Do you authorize CAIR-MO to give the media your contact information? *

Yes

No