Zip CodeCountyZip CodeCountyI believe I was discriminated against because of my Please identifyRaceColorReligionSexNational OriginAncestryRetaliationDisabilityMilitary StatusAge Over 40 years old on ID: 869098
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1 CHARGE NUMBER: Zip CodeCountyZip CodeCou
CHARGE NUMBER: Zip CodeCountyZip CodeCounty I believe I was discriminated against because of my: (Please identify)Race/ColorReligionSexNational Origin/AncestryRetaliationDisabilityMilitary StatusAge (Over 40 years old only - List Date of Birth)FOR AGE CASES ONLY: I have not commenced any action under sections 4112.14 or 4112.02(N), Revised Code with respect to the subject matter of theaffidavit. I understand that upon filing of this charge with the Ohio Civil Rights Commission, I am barred from instituting any such civil action and that any Type of Discrimination:DemotionDischarge/TerminationDisciplineFailure to HireHarassment/Sexual HarassmentForced to ResignPromotionReasonable AccommodationLayoffOther (Specify) Please write a brief but detailed statement of the facts that you believe indicate an unlawful discriminatory practice
2 . Please write legibly. Notary or Ohio C
. Please write legibly. Notary or Ohio Civil Rights Commission RepresentativeI declare under penalty of perjury that I have read the above charge and that it is true tothe best of my knowledge, information and belief. I will advise the agency(ies) if I Subscribed and sworn to before me on this20day of DateCharging Party SignatureNotary or Commission Representative(Agency Use Only) Page: 2 Notary or Ohio Civil Rights Commission RepresentativeI declare under penalty of perjury that I have read the above charge and that it is true tothe best of my knowledge, information and belief. I will advise the agency(ies) if I Subscribed and sworn to before me on this20day of DateCharging Party SignatureNotary or Commission Representative CHARGE NUMBER: Agency Use OnlyOHIO CIVIL RIGHTS COMMISSIONCHARGE OF DISCRIMINATIONFEPAEEOC(Agency Use Only