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2. If you have a complaint under Ordinance No. 95-92 or 2003-66 complete this form and mail or deliver it to the Carbondale City Clerk's Office, P.O. Box 2047, Carbondale, IL 62902-2047 within 30 days from the commission of the alleged violation or 180 days in the case of a relocation grievance.
4. Name*
5. Email Address*
7. Address*
9. City*
10. State*
11. Zip Code*
13. Phone Number*
15. I may also be contacted through
17. Name*
18. Email Address
20. Address*
22. City*
23. State*
24. Zip Code*
26. Phone Number*
28. List the party or parties who allegedly discriminated against you
30. Name*
31. Phone*
32. Company Name (if known)
34. Address*
36. City*
37. State*
38. Zip Code*
40. Other Parties (if any)
42. Cause of discrimination (check all that apply)*

    1. Race
    2. Color
    3. Religion
    4. National Origin or Ancestry
    5. Marital Status

    1. Sex
    2. Age
    3. Disability
    4. Sexual Orientation
    5. Familial Status
43. Date of alleged violation*
45. Specifically describe the act and how you believe you were treated differently than other persons. (Attach separate sheet if necessary)*
47. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
49. Electronic Signature*
51. AFFIDAVIT*

    I swear or affirm that I am the Complainant herein and that I have read the above complaint and that it is true to the best of my knowledge, information and belief.

    1. I agree.
53. Electronic Signature*
Leave This Blank:


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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