The Montgomery College Advantage
OFFICE OF EQUITY AND DIVERSITY FORMAL COMPLAINT OF DISCRIMINATION


COMPLAINANT:
Name: Title:
Department:    
Campus* (Check the appropriate box.):
C G R T GBTC WS
Home Address:
City/State/Zip:
Telephone #:
E-Mail Address(es): 
COMPLAINANT'S STATUS: (Check the appropriate box.)
Student Faculty
Staff: Administrative Associate Support
Applicant for employment

PROTECTED CLASS:
(Check the appropriate box(es) indicating the classification that is applicable to your complaint.)
Age Race Color Gender Sexual Orientation Religion
National Origin Ancestry Marital Status Veteran Disabled
Disabled Vietnam Era Other 
DESCRIPTION OF THE ALLEGED DISCRIMINATORY ACTION(S):
A. Describe the alleged discriminatory action(s). Be as precise as possible with regard to the names and titles/positions of the involved participants, names and titles/positions of witnesses, locations, times, dates and provide other information relevant to this complaint.
(If your text exceeds the textbox size, please use additional sheets of paper.)
 
B. Indicate why you believe the action is based on discrimination. For example, why is the discrimination based on your age, race, color, gender, sexual orientation, religion, national origin, ancestry, marital status, veteran, disabled, disabled Vietnam era or other?
(If your text exceeds the textbox size, please use additional sheets of paper.)
 

PROPOSED RESOLUTION AND/OR REMEDIAL ACTION(S) YOU ARE SEEKING:
Describe the proposed resolution and/or corrective actions you are seeking.
(If your text exceeds the textbox size, please use additional sheets of paper.)
 

What external agencies have been contacted regarding this complaint?
Name of Agency:     Date: 
Name of Agency:     Date: 
Name of Agency:     Date:
____________________________________________________
Signature of Complainant 		_________________________
Date
____________________________________________________
Representative, Office of Equity and Diversity

_________________________
Date