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2. Filing a complaint

   Please complete the form and either submit electronically or print, complete and send to City of Grand Junction ATTN: Wanda Winkelman 250 N. 5th St. Grand Junction, CO 81501

4. Name
5. Phone Number (Home or Cell)
7. Address
9. City
10. State
11. Zip Code
13. Person Discriminated Against (if different than above)
14. Phone Number (Home or cell)
16. Address
18. City
19. State
20. Zip Code
22. Which of the following best describes the reason you believe the discrimination occurred?

    1. Race/color
    2. Gender

    1. Sexual Orientation
    2. Religion

    1. National Origin
    2. Age

    1. Disability
    2. Other
24. If 'other' was selected, please specify:
26. On what date or dates did the alleged discrimination occur?
28. Describe the alleged discrimination; what happened and who you believe to be responsible.
30. List names and contact information of those who may have knowledge of the alleged discrimination.
32. Have you filed a complaint with any other federal, state or local agency or with any federal or state court? Check all that apply.

    1. Federal Agency
    2. Federal Court

    1. State Agency
    2. State Court

    1. Local Agency
34. Please provide contact information for the agency or court when the complaint was filed.
36. Name of Agency and Contact Person
37. Phone Number
39. Address
41. City
42. State
43. Zip Code
45. Signature:
46. Date:
Leave This Blank:


48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit

* indicates a required field