CONSUMER DISCRIMINATION INITIAL QUESTIONNAIREYOUR RESPONSES WILL BE KEPT CONFIDENTIAL*Once you submit the form, we will contact you within 48 hours* Complete Name Cell Your email Name of business in which incident took place. Date and time you went to the business. Was your intention to buy something at this business? Despite the incident, did you ultimately purchase what you wanted? Who was with you? And Did they witness the incident? Give a brief summary of what happened. Include name, race, and gender of any employee(s), along with any racist slurs or racially offensive language that was directed at you. Also include any other form of aggression that you were made subject to (physical assault, insults based on gender, age, etc.) Were you trespassed from the business? YesNoWere you arrested as a result of this incident? YesNoDo you have any photo/video of the incident? YesNoDid you report this incident to corporate? YesNoWere you offered any form of compensation by corporate? YesNo City and State in which incident took place. Δ
