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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:
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City:
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State:
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WA
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GA
HI
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*
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?
No
Yes
What language should we contact you in?
2
Information About the Employer
*
Employer Name:
Address:
City:
State:
Select State
WA
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MH
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
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ND
MP
OH
OK
OR
PA
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VA
WV
WI
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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?
No
Yes
*
Is this complaint about an employer's job advertisement?
No
Yes
*
Is this complaint about an employer's job application?
No
Yes
*
Is this complaint about an employer's hiring process other than the job advertisement or job application?
No
Yes
For what position did the applicant apply?
*
Was the applicant hired for the job?
No
Yes
Unknown
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:
Javascript is not enabled in your internet browser. Only one file per complaint may be uploaded if Javascript is not enabled.
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
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Name:
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