Complaint of Harassment or Discrimination

Instructions: An application form is must on the part of complainant. Submit the form to the committee members appointed by the college. The Complainant will have to appear for personal interaction with committee members.

Today's Date *

Your Name *

Date of Birth *

Department / Class *

Contact Information (Home Address) *
plz mention: Number, Street, City, State, Zip

Personal Phone *

Home Phone / Cell

Email *

Person(s) against whom complaint is being made *

Allegations *
Include dates and locations. Use additional sheets if necessary.

Has anyone been notified of this incident? If so, who and when:

Are there any other witnesses to the incident(s)? If so, who?

Submit Complaint