Ban The Box Complaint Form

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Panel - Prospective Employer Information
Panel - Employee Information
Panel - Complaint Information
Panel - Signature Information

Prospective Employer Information

Prospective Employer Business Name

Prospective Employer Address

Prospective Employer City

Prospective Employer State

Prospective Employer ZIP Code

Prospective Employer County

Prospective Employer Contact Name

Prospective Employer Contact Phone

Prospective Employer Email

Prospective Employer Website

Industry

Complaintant Information

First Name

Last Name

Address

City

State

ZIP Code

County

Phone

Check this box if you consent to service of process via electronic mail at the email address provided above.

Complaint Information

Date/Time Period of the alleged violation From

Date/Time Period of the alleged violation To

Position Applied For

Does the Employer have 15 or more employees in the current or preceding calendar year?

Have you been asked to disclose your criminal record or criminal history before being notified that you were selected for an interview?

Did you receive a conditional offer of employment

Yes

If yes, when did you receive the offer?

Have you been asked to disclose your criminal record or criminal history before a conditional offer of employment?

Is a bond required for the position applied for?

Does the position applied for require a license under the Emergency Medical Services Systems Act?

BY ACCEPTING AND SUBMITTING THIS FORM, THE COMPLAINANT AFFIRMS AND CERTIFIES THAT ALL INFORMATION PROVIDED AND THE STATEMENTS MADE HEREIN ARE TRUE, CORRECT, AND COMPLETE.

Type your name as signature.

Signature Date

Ban The Box Complaint Form

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Ban The Box Complaint Form

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