Fax to 512-486-5539. Last Name First Name Mailing Address: City: State: Phone Number: Zip Code: Alternative Phone Number: Email: Please indicate the basis of your complaint: Race National Origin Color Disability Date and place of alleged discriminatory action(s). Please include the earliest date of discrimination and the most recent date of discrimination. How were you discriminated against? Describe the nature of the action, decision, or conditions of the alleged discrimination. Ex.
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