Report Discrimination Name * First Name Last Name Email * Incident Date MM DD YYYY Mobile Number (###) ### #### Home Number (###) ### #### Work Number (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Ethnic Background Religion Filer Name (if different) First Name Last Name The media regularly contacts CAIR-Chicago for information on cases. Do you authorize CAIR-Chicago to give the media your contact information? Yes No Please provide a detailed description of the incident below. Include date, time, witnesses, and any evidence of religious discrimination: Offending Party's Information Name First Name Last Name Email Mobile Number (###) ### #### Home Number (###) ### #### Work Number (###) ### #### Gender Male Female Other Address Address 1 Address 2 City State/Province Zip/Postal Code Country Thank you!
