Date of Submission of Application
Part 1 - About you
ID Card No
Building Entry Point Name
Would you like NCPE to send all relevant correspondence to this address?
If not, where would you like correspondence to be sent to?
Only fill out this box if you are complaining on behalf of someone else
Name of that person
Address & postcode
Home Tel. No.
Work Tel. No.
What is your connection to the person suffering the alleged discrimination?
Does the individual concerned know you are filing in this form?
What is the reason you are filling in this form?
Only fill out this box if someone is assisting you with the complaint - for example, a lawyer, or union representative
Name of representative
Part 2 - Your complaint
Who are you complaining about?
Name / Organisation
What is the person's / organisation's connection to you?
If you are complaining about more than one person / organisation
Describe the events that you want to complain about. We need to know your version of the facts on what happened, where it happened, who did it, if there were any witnesses and any other information which you deem relevant. Give us all the dates and other details that you can remember. If you are complaining about employment, please tell us when you commenced employment, your job title and whether you are still employed. Kindly highlight where you are identifying discrimination.
When did it happen? (day / month / year)
I hereby certify that the information I have provided in this complaint is true, correct and complete to the best of my knowledge and belief.
Please note that a copy of this form will be forwarded to the person against whom the complaint is being filed. If the complaint so warrants, a copy will also be forwarded to the employer.
Date (date / month / year)
Indicate the situations that are relevant to your case:
I am complaining because while accessing to and/or seeking the supply of goods & services:
I am complaining because I believe:
Others (please specify)
I want to complain about:
I am a European Union citizen worker/a family member of a European Union citizen worker and I am complaining because I believe I have encountered/am encountering obstacles to exercise my free movement rights as a worker/have had/am having my right to free movement for workers restricted without justification/the principle of equal treatment is not being applied in:
Part 3 - Further information
Please attach copies of any documents that may help us to address your complaint (for example, letters, pay slips, doctor’s certificates or references). If you cannot do this, please tell us about the documents or other evidence and how this evidence can be obtained.
What support are you expecting from NCPE vis-à-vis your complaint?
Have you made a complaint about this to another agency?
(For example a Trade Union, Police, Department of Industrial and Employment Relations, an Ombudsman etc.)If so, provide details of the complaint, the agency it was made to and any outcome. Also attach copies of any letters you have received from the agency.
Have you tried to resolve your complaint in any other way?
(For example through an internal complaint process etc)If so, give details:
Part 4 - Consent for NCPE to take action
Would you like NCPE to take immediate action upon receiving your complaint and contact the alleged harasser/ perpetrator?
Would you like to keep your complaint on hold for now? (Kindly note NCPE will keep your complaint on hold for a maximum of 6 months)
Remember to: sign page 5 of this form, and attach any relevant documentation.
Confidentiality: The National Commission for the Promotion of Equality maintains confidentiality. Every effort is made to keep information regarding complaints confidential without compromising the enquiry. Information is shared only with those who have a legitimate need to know.The Data Protection Act 2001: The Data Protection Act 2001 was enacted on the 14 December 2001 and came fully into force on the 15 July 2003. We therefore have a legal duty to respect and protect any personal information we collect from you and we will abide by such duty. We take all safeguards necessary to prevent unauthorised access and we do not pass on your details collected from you as a client, to any third party or Government Department unless you give us your consent to do so.
If you need help in filling in this form, contact NCPE on 2295 7850 / email@example.com for an appointment.