Fair Chance Jobs Complaint Form

* Starred fields are mandatory in order to process your request.

1 Information About You

*Last Name:

*First Name:

Middle Name:

*Address:

*City:

*State:

*Zip:

*Contact Phone

Best day(s) of the week and time(s) of day to reach you by phone

*Contact e-mail address:

*Confirm e-mail address:

*Is this complaint about you? NoYes

What language should we contact you in?

2 Information About the Employer

*Employer Name:

Address:

City:

State:

Select State

Zip:

Contact Person at Employer:

*Last Name:

*First Name:

Employer Website:

Employer Phone Number:

3 Information About this Complaint

*Is this a Fair Chance Act / Ban the Box complaint? Put another way, does this complaint involve an employer asking about a job applicant's criminal record before determining if the applicant was otherwise qualified for the position, or automatically excluding an applicant because of their criminal record? NoYes

*Is this complaint about an employer's job advertisement? NoYes

*Is this complaint about an employer's job application? NoYes

*Is this complaint about an employer's hiring process other than the job advertisement or job application? NoYes

For what position did the applicant apply?

*Was the applicant hired for the job? NoYesUnknown

4 Documents

You may upload 5 files with a total file size limit of 20 megabytes, including a copy or photo of any job advertisement or blank job application form about which you are complaining.

Accepted Document Types: TXT, DOC, DOCX, XLS, XLSX, PDF
Accepted Image Types: JPG, TIF, TIFF, PNG, JPEG

Upload Attachments:

5 Privacy Notice, disclaimer and signature

Some or all of the information submitted on this form may constitute a public record. By selecting YES below, I acknowledge that my complaint and attachments, once submitted, may become a public record subject to review by the Attorney General's Office for applicable restrictions on disclosure. If you would rather submit your complaint via phone, you may do so by leaving a message at (833) 662-9934 and a staff member will return your call.

Yes

*Name:

*Date

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