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Get Tx Pers 497 2014

Address: Home or Cell Phone #: (Area Code) Street Address City State Zip Name of Warden or Department Head: Respondent Information (Person Complained Against) Name: Title: Date(s) of Discriminatory Event: Are you complaining about: Unit or Dept: Earliest: Latest: Slurs or Hostile Epithets? (Check) Yes No If yes, explain: Color Discrimination? Yes No If yes, identify your color: Race Discrimination? Yes No If yes, identify your race: National Origin Discrimination? Yes No.

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