You are not at liberty to violate my rights.  This establishment is prohibited by law from discriminating against an individual based on age, gender, ethnicity, medical condition or religious beliefs. Civil Rights Act of 1964

DATE of Violation: ______________________________________________________________

NAME of Violator: ______________________________________________________________

(If identity is not given, provide physical description of violator):


Name of business: ______________________________________________________________

Location of Incident: ____________________________________________________________

Description of Incident: (attach additional sheets if needed): ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

The above named violator of my Civil rights has been informed of U.S. Law and has willingly and knowingly refused my free and equal entry and access to all services and facilities as required by law. This individual has been served a NOTICE OF DISCRIMINATION and has been informed that CHARGES may be filed in the Civil Rights Division of the Department of Justice and/or with the United States District Attorney and/or in the U.S. District Court for this willful violation of my U.S. Civil Rights. 

Signature of injured party: _____________________________________________________Date:_____________________________

PRINT FULL NAME: _______________________________________________________________________________________________

Signature of violator: ___________________________________________________________Date:_____________________________

PRINT FULL NAME: _______________________________________________________________________________________________

_______ CHECK here if violator refuses to sign NOTICE OF DISCRIMINATION

 WITNESS (optional) Name: ____________________________________________________________



Federal law prohibits privately owned facilities including retail establishments, medical offices and those that offer food, lodging, gasoline or entertainment to the public from discriminating on the basis of race, color, religion, medical condition, disability or national origin. 


The U.S. Department of Justice Civil Rights Division DOJ is required to investigate complaints of discrimination on the basis of race, color, national origin, sex, disability age and religion.

Fill out this form is you have been discriminated against in a place of public accommodation ie, a retail establishment, doctor's office, entertainment facility, places that offer food/ lodging/gas etc.