Discrimination Witness Statement | Civil Rights, City of Madison, Wisconsin

*indicates required fields

I want the Department of Civil Rights to contact me about this. *

Yes

Are you submitting this witness statement for a current case of discrimination? *

Yes

My Contact Information

First Name

First Name *

Last Name

Last Name *

I do not have a permanent address or prefer not to provide it.

Address 1

Address 1 *

Address 2

City

City *

State

State *

Zip code

Zip code *

Phone

Phone *

Email *

Confirm Email

Name of Business where discrimination occurred

First Name *

Last Name *

Type of Problem *

Explain what you witnessed

Where did this happen? *

City

State

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Signature

Signature *