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HousingDescrimitationForm.html
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HousingDescrimitationForm.html
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<!-- ---------------------------------------------------------------------- -->
<!-- NOTE: Please add the following <META> element to your page <HEAD>. -->
<!-- If necessary, please modify the charset parameter to specify the -->
<!-- character set of your HTML page. -->
<!-- ---------------------------------------------------------------------- -->
<META HTTP-EQUIV="Content-type" CONTENT="text/html; charset=UTF-8">
<!-- ---------------------------------------------------------------------- -->
<!-- NOTE: Please add the following <FORM> element to your page. -->
<!-- ---------------------------------------------------------------------- -->
<form action="https://webto.salesforce.com/servlet/servlet.WebToCase?encoding=UTF-8" method="POST">
<input type=hidden name="orgid" value="00D8c000004cyMU">
<input type=hidden name="retURL" value="https://nationalfairhousing.org/what-is-housing-discrimination/">
<!-- ---------------------------------------------------------------------- -->
<!-- NOTE: These fields are optional debugging elements. Please uncomment -->
<!-- these lines if you wish to test in debug mode. -->
<!-- <input type="hidden" name="debug" value=1> -->
<!-- <input type="hidden" name="debugEmail" -->
<!-- value="[email protected]"> -->
<!-- ---------------------------------------------------------------------- -->
Name<br>
First <input id="00N8c00000hQhsy" maxlength="255" name="00N8c00000hQhsy" size="20" type="text" />
Last <input id="00N8c00000hQht1" maxlength="255" name="00N8c00000hQht1" size="20" type="text" /><br>
Preferred Pronouns (optional) <br> <input id="00N8c00000hQht7" maxlength="255" name="00N8c00000hQht7" size="20" type="text" /><br>
<input id="00N8c00000hQhsq" name="00N8c00000hQhsq" type="checkbox" value="1" /> Asian <br>
<input id="00N8c00000hQhso" name="00N8c00000hQhso" type="checkbox" value="1" /> American Indian or Alaskan Native <br>
<input id="00N8c00000hQht4" name="00N8c00000hQht4" type="checkbox" value="1" /> Native Hawaiian or Other Pacific Islande <br>
<input id="00N8c00000hQhtB" name="00N8c00000hQhtB" type="checkbox" value="1" /> White <br>
<input id="00N8c00000hQht0" name="00N8c00000hQht0" type="checkbox" value="1" /> Hispanic or Latino <br>
<input id="00N8c00000hQhsr" name="00N8c00000hQhsr" type="checkbox" value="1" /> Black or African American <br>
<input id="00N8c00000hQht6" name="00N8c00000hQht6" type="checkbox" value="1" /> Other <br>
<label for="email">Email Address</label><br>
<input id="email" maxlength="80" name="email" size="20" type="text" /><br>
<label for="phone">Phone Number <br>
</label><input id="phone" maxlength="40" name="phone" size="20" type="text" /><br>
City <br>
<input id="00N8c00000hQhss" maxlength="255" name="00N8c00000hQhss" size="20" type="text" /><br>
State <br>
<select id="00N8c00000hQht9" name="00N8c00000hQht9" title="State"><option value="">--None--</option><option value="Alabama">Alabama</option>
<option value="Alaska">Alaska</option>
<option value="Arizona">Arizona</option>
<option value="Arkansas">Arkansas</option>
<option value="California">California</option>
<option value="Colorado">Colorado</option>
<option value="Connecticut">Connecticut</option>
<option value="Delaware">Delaware</option>
<option value="Florida">Florida</option>
<option value="Georgia">Georgia</option>
<option value="Hawaii">Hawaii</option>
<option value="Idaho">Idaho</option>
<option value="Illinois">Illinois</option>
<option value="Indiana">Indiana</option>
<option value="Iowa">Iowa</option>
<option value="Kansas">Kansas</option>
<option value="Kentucky">Kentucky</option>
<option value="Louisiana">Louisiana</option>
<option value="Maine">Maine</option>
<option value="Maryland">Maryland</option>
<option value="Massachusetts">Massachusetts</option>
<option value="Michigan">Michigan</option>
<option value="Minnesota">Minnesota</option>
<option value="Mississippi">Mississippi</option>
<option value="Missouri">Missouri</option>
<option value="MontanaNebraska">MontanaNebraska</option>
<option value="Nevada">Nevada</option>
<option value="New Hampshire">New Hampshire</option>
<option value="New Jersey">New Jersey</option>
<option value="New Mexico">New Mexico</option>
<option value="New York">New York</option>
<option value="North Carolina">North Carolina</option>
<option value="North Dakota">North Dakota</option>
<option value="Ohio">Ohio</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oregon">Oregon</option>
<option value="PennsylvaniaRhode Island">PennsylvaniaRhode Island</option>
<option value="South Carolina">South Carolina</option>
<option value="South Dakota">South Dakota</option>
<option value="Tennessee">Tennessee</option>
<option value="Texas">Texas</option>
<option value="Utah">Utah</option>
<option value="Vermont">Vermont</option>
<option value="Virginia">Virginia</option>
<option value="Washington">Washington</option>
<option value="West Virginia">West Virginia</option>
<option value="Wisconsin">Wisconsin</option>
<option value="Wyoming">Wyoming</option>
</select><br>
Zip Code <br>
<input id="00N8c00000hQhtC" maxlength="255" name="00N8c00000hQhtC" size="20" type="text" /><br>
What Happened? <br>
<textarea id="00N8c00000hQhtA" name="00N8c00000hQhtA" rows="3" type="text" wrap="soft"></textarea><br>
Does this complaint involve appraisal discrimination? <br>
<select id="00N8c00000hQhsp" name="00N8c00000hQhsp" title="Appraisal Discrimination"><option value="">--None--</option><option value="Yes">Yes</option>
<option value="No">No</option>
</select><br>
Are you a reporting information about your employer or your former employer? <br>
<select id="00N8c00000hQht8" name="00N8c00000hQht8" title="Reporting on Employee or Former Employee"><option value="">--None--</option><option value="Yes">Yes</option>
<option value="No">No</option>
</select><br>
On which of the following do you believe the discrimination was based?<br>
<select id="00N8c00000hQhsu" multiple="multiple" name="00N8c00000hQhsu" title="Complaint Protected Class"><option value="Race">Race</option>
<option value="Disability">Disability</option>
<option value="Familial Status">Familial Status</option>
<option value="Sex">Sex</option>
<option value="National Origin">National Origin</option>
<option value="Color">Color</option>
<option value="Religion">Religion</option>
<option value="Sexual orientation, gender identity, or expression">Sexual orientation, gender identity, or expression</option>
<option value="Military status/history">Military status/history</option>
<option value="Source of Income">Source of Income</option>
<option value="Other">Other</option>
</select><br>
Complaint Protected Class Other <input id="00N8c00000hQhst" maxlength="255" name="00N8c00000hQhst" size="20" type="text" /><br>
<label for="company">Company</label><input id="company" maxlength="80" name="company" size="20" type="text" /><br>
<label for="name">Contact Name</label><input id="name" maxlength="80" name="name" size="20" type="text" /><br>
Most Recent Date of Discrimination <input id="00N8c00000hQht3" maxlength="255" name="00N8c00000hQht3" size="20" type="text" /><br>
Have you informed other parties <select id="00N8c00000hQhsz" name="00N8c00000hQhsz" title="Have you informed other parties"><option value="">--None--</option><option value="Yes">Yes</option>
<option value="No">No</option>
</select><br>
Other Organizations Contacted <textarea id="00N8c00000hQht5" name="00N8c00000hQht5" rows="3" type="text" wrap="soft"></textarea><br>
Lawsuit or Complaint filed <select id="00N8c00000hQht2" name="00N8c00000hQht2" title="Lawsuit or Complaint filed"><option value="">--None--</option><option value="Yes">Yes</option>
<option value="No">No</option>
</select><br>
<input type="hidden" id="external" name="external" value="1" /><br>
<input type=hidden name="recordType" id="recordType" value="0128c000001SMVe">
<input type="submit" name="submit">
</form>