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2. First Name
3. Last Name
5. Address
7. City
8. State
9. Zip
11. Cell Phone
12. Work Phone
14. Email
16. Describe the basis of the alleged discrimination:
18. What Town department or employee(s) was involved (if known):
20. The date on which the events occurred:
    The date on which the events occurred:
22. Describe how, when and why you believe you were excluded from participation in, were denied the benefits of, or were subjected to discrimination:
24. Name and contact information of any witnesses:
26. Has another complaint with another agency been filed?

    1. Yes
    2. No
28. If yes, name the agency, date of complaint, and contact information for that agency if available:
30. Name of Complaintant
31. Today's Date
    Today's Date
33. How to Submit This Form

    Click the submit button below or send a printed form to the Town Attorney's Office at PO Box 8, Holly Springs, NC 27540. 

Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field