Immigrant and employee rights

Immigrant and Employee Rights Section (IER)

IER Charge Form

Affirmation and Signature of Charging Party

I affirm that, to the best of my knowledge, the information provided on this form that is shown below is true and that I am authorized to file this charge on behalf of the Injured Party. I understand that IER may find it necessary to reveal my identity during the investigation of this charge, during a hearing or other proceeding as a result of this charge, or in limited circumstances in response to inquiries under the Freedom of Information Act. I give my consent to such disclosures.
Filing Supporting Documents
You cannot attach supporting documents directly to this form. If you want to submit other documents, you can do so by using the following instructions. Please only send copies of documents, not originals. When transmitting attachments or documents relating to this form, please include the reference number that will generate once you have submitted the form.
By Email:
If you provide an email address, you will receive a confirmation email once we receive your form. If you would like to attach files or documents to support your form, you may submit them by replying to the confirmation email and attaching the files to your reply message.
By Mail:
You may mail any attachments or documents to support your form to:

Immigrant and Employee Rights Section
Civil Rights Division
US Department of Justice
950 Pennsylvania Avenue, NW (NYA)
Washington, DC 20530

By Fax:
You may also fax attachments or documents to support your form to 202-616-5509.
   

Section 1: Injured Party Contact Information

Gender	Male
Full Name *	hemal
Street or Mailing Address *	10519 pickerel lane charlotte North Carolina United States 28213
Telephone - Home	704-547-8379
Telephone - Cell	980-267-5497
Telephone - FAX
Email	hemalshahusa@gmail.com
Would you like us to communicate with the Injured Party in another language?
Specify language	English
What are the best times to contact the Injured Party by telephone (if not represented)?	9:00Am to 3:00 Pm

Section 2: Injured Party’s Citizenship or Immigration Status Information

Please provide Injured Party’s citizenship or immigration status or work authorization type: *	Citizen
Please specify:
Alien #/USCIS #
Admission #

Section 3: Injured Party’s National Origin and Other Personal Information

What is the Injured Party’s country of birth? *	India
What is the Injured Party’s national origin (ancestry)? *	India
What is the Injured Party’s date of birth?	Day 19 Month 04 Year 1967

Section 4: Type of Discrimination Alleged

What type of discrimination is being alleged?*Check all that apply:	National Origin Discrimination Citizen Status Discrimination

Section 5: Employer Information

Company (Employer) Name *	staffmark
Street or Mailing Address	230 E W.T. Harris Blvd harlotte North Carolina 28262
Telephone	704-503-0029
If you know, does the Company operate under any other names?	No
If yes, under what other name(s)?
Number of Employees the Company or Employer employs *	Don't know/Unable to estimate

Section 6: Date and Place the Discrimination Occurred and the Specifics of the Discrimination Alleged

When did the discrimination occur?	Day 17 Month * 08 Year * 2017
Where did the discrimination occur?	Charlotte charlotte North Carolina
Explain in detail what happened when the Injured Party was discriminated against. * Include whether the Injured Party was fired, laid-off, not hired, delayed start date, asked for additional documents, retaliated against, or other, and describe what happened in detail.	I feel out job application with Staffmark staffing agency According to them they Do not have job on the day 07-18-2017 they will going to call me once position available for pick and pack.i wait few day I got automatic message from them they got a hiring . I stop by in office staffmark employee report me they send message to every one(it is automatic message.i attended one of j ob fair I founded this agency.i reported i had a experience and i am ready to start work,she told me i have to apply again i check on computer all full application i am done with them i do not need to do it again.after few day they insult me.you do not have experience you need to update experience in Resume.why they not hiring me?i feel it is nationality discrimination. eeoc send this link i request Job discrimination form. 2 second issue 2014 unpaid wage Reported to agency.charge file against EEOC

Section 7: Charges Filed with Other Federal or State Agencies Based on the Same Facts

Has a charge based on this set of facts been filed with any federal, state, or local governmental agency?	Yes
Full Agency Name	staffmark
Agency Street or Mailing Address	230 E W.T. Harris Blvd charlotte North Carolina 28262
Telephone	7045030029
Date Filed	Day 10 Month 10 Year 2017
File No.
Investigator Name

Section 8: Charging Party Contact Information (Injured Party or person filing charge on the Injured Party’s behalf)

Is the Charging Party the same as the Injured Party? *	No
Gender	f
Full Name *	hemal shah
Title	employee
Entity Name *	hemal
Street or Mailing Address *	10519 pickerel lane charlotte North Carolina 28213
Telephone	704-547-8379
FAX
Email	hemalshahusa@gmail.com
What are the best times to contact the Charging Party?

Section 9: Communications with IER

Have you previously spoken or communicated with IER prior to filing this charge?	No
When?	Day Month Year
How?
If you know, what is the name of the IER representative you spoke to or communicated with?

Section 10: Optional Information

How did you hear of IER?	IER Outreach Equal Employment Opportunity Commission (EEOC)
The Injured Party is:	Asian

---

Privacy Act Statement

The authority for requesting this information from the Injured or Charging Party is contained in 8 U.S.C. § 1324b. The information that the Injured or Charging Party provides will be used principally for investigating and processing the charge of prohibited discrimination; however, the information may also be used for other legitimate purposes, as detailed in the Department of Justice’s Federal Register Notice published in the Federal Register at 68 Fed. Reg. 47611 (August 11, 2003) describing the routine uses of the information obtained by the Civil Rights Division. The Injured or Charging Party’s failure to provide the information requested on this form could lead to the charge being dismissed or not being accepted. Knowingly making false statements on this form is punishable under 18 U.S.C. § 1001.

Paperwork Reduction Act Notice

This request is in accordance with the Paperwork Reduction Act of 1995. The information collection is necessary to enable the Department to process and investigate individual charges of discrimination in violation of 8 U.S.C. § 1324b as required by statutory mandate. The use of this collection instrument will facilitate this process by assisting charging parties to identify and provide the information necessary to initiate an investigation.

The estimated average burden associated with this collection is 30 minutes per charging party or recordkeeper, depending on individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to IER's Special Policy Counsel, USDOJ-CRT-IER, 950 Pennsylvania Avenue, NW-NYA, Washington, DC 20530.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

OMB Number: 1190-0018
Revised date: 02/09/2017