If you or someone you know has been a victim of an anti-Muslim hate crime, or an act of discrimination, kindly fill out this form to have your case reviewed by the CAIR-Chicago’s civil rights department. Please note that your identity will remain confidential.

Your Information

Your Name (required):

Your Email (required):

Incident Date: (Ex: 09/17/1976)

Mobile Number:

Home Number:

Work Number:

Fax:

Gender:

---MaleFemale

Street Address:

City:

State:

Zip Code:

Ethnic Background:

Religion:

Filer Name*?

*Please enter if different from above

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Please provide a detailed description of the incident below. Include date, time, witnesses, and any evidence of religious discrimination:

Offending Party's Information:

Name

E-mail:

Mobile Number:

Home Number:

Work Number:

Fax:

Gender:

---MaleFemale

Street Address

City:

State:

Zip Code: