The U.S. Equal Employment Opportunity Commission
OFFICE OF FEDERAL OPERATIONS
P.O. Box 77960
Washington, DC 20013
Complainant Information: (Please Print or Type)
Complainant's name (Last, First, M.I.): | |
Home/mailing address: | |
City, State, ZIP Code: | |
Daytime Telephone # (with area code): | |
E-mail address (if any): |
Attorney/Representative Information (if any):
Attorney name: | |
Non-Attorney Representative name: | |
Address: | |
City, State, ZIP Code: | |
Telephone number (if applicable): | |
E-mail address (if any): |
General Information:
Name of the agency being charged with discrimination: | |
Identify the Agency's complaint number: | |
Location of the duty station or local facility in which the complaint arose: | |
Has a final action been taken by the agency, an Arbitrator, FLRA, or MSPB on this complaint? | _____Yes; Date Received ____________(Remember
to attach a copy) _____No _____This appeal alleges a breach of settlement agreement |
Has a complaint been filed on this same matter with the EEOC, another agency, or through any other administrative or collective bargaining procedures? | _____No ____Yes (Indicate the agency or procedure, complaint/docket number, and attach a copy, if appropriate) |
Has a civil action (lawsuit) been filed in connection with this complaint? | _____No _____Yes (Attach a copy of the civil action filed) |
NOTICE: Please attach a copy of the final decision or order from which you are appealing. If a hearing was requested, please attach a copy of the agency's final order and a copy of the EEOC Administrative Judge's decision. Any comments or brief in support of this appeal MUST be filed with the EEOC and with the agency within 30 days of the date this appeal is filed. The date the appeal is filed is the date on which it is postmarked, hand delivered, or faxed to the EEOC at the address above.
Signature of complainant or complainant's representative: | |
Date: |
EEOC Form 573 REV 1/01
(This form is covered by the Privacy Act of 1974. Public Law 93-597. Authority for requesting the personal data and the use thereof are given below.)
Send your appeal to:
The Equal Employment Opportunity Commission
Office of Federal Operations
P.O. Box 77960
Washington, D.C. 20013
This page was last modified on January 9, 2009.