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<!DOCTYPE html>
<html lang="en">
<head>
<title>DOL FORMS</title>
<!------------------------------------
META
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<meta http-equiv="Content-type" content="text/html;charset=UTF-8">
<meta http-equiv="Content-Style-Type" content="text/css">
<meta name="generator" content="">
<meta name="viewport" content="width=device-width, initial-scale=1">
<!------------------------------------
LINK
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<link rel="stylesheet" type="text/css" media="all" href="dol_style.css">
<script src="dol_style.js"></script>
</head>
<!------------------------------------
COMPLAINT FORM
------------------------------------->
<body>
<form name="myform" action="http://www.conceptlabs.com/viateq/demo/complaint_submission.asp" method="POST">
<div id="DOL_FORM">
<!-----------------
Heading
------------------>
<div style="background-color:white; width: 300px; height: 140px; border:none;">
<img src="icon-dol.jpg" align="top" width="45" border="0" alt="Department of Labor" title="Department of Labor">
<img src="icon-ofccp.jpg" align="top" width="155" border="0" alt="Office of Federal Contract Compliance Programs" title="Office of Federal Contract Compliance Programs">
<div style="background-color:white; width: 300px; height: 140px; border:none; margin-top: 5px;" >
<p>OMB: 1250-0002</p>
<p>Expires: XXXX</p>
</div>
</div>
<div style="background-color:white; width: 440px; height: 140px; border:none;" >
<h1 style="text-align:right;" >Complaint Involving Employment Discrimination by a Federal Contractor or Subcontractor</h1>
<a href="english_form_instructions.html" target="_blank" >Please read the instructions before completing this form.</a>
<p class="newline"></p>
<button class="right" onclick="validateForm()">Submit</button>
<button class="right" onclick="clear_form()">Reset Form</button>
<button class="right" onclick="print_form()">Print Form</button>
<input type="submit" value="Submit">
</div>
<!-----------------
Section 1
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<! Row 1>
<div style="background-color:coral; width: 150px; height: 206px;">
<h2>How can we reach you?</h2>
</div>
<div style="background-color:pink; width: 585px; height: 206px;">
<input type="hidden" name="Form_Language" value="English">
<div style="background-color:pink; width: auto; height: 25px; border:none; padding:0;">
<label for="Fullname1">Name (First, Middle, Last):</label>
<input size= "40" type="text" name="Fullname1" id="Fullname1" onchange="check_name('Fullname1')">
</div>
<div style="background-color:pink; width: auto; height: 25px; border:none; padding:0;">
<label for="Address1">Street Address:</label>
<input size= "40" type="text" name="Address1" id="Address1" onchange="check_address('Address1')">
</div>
<div style="background-color:pink; width: auto; height: 23px; border:none; padding:0;">
<label for="City1">City:
<input bgcolor="#3CBC8D" size= "20" type="text" name="City1" id="City1" onchange="check_cityname('City1')"></label>
<label for="state1">State:
<select name="state1" id="state1" size="1">
<option value="">Select a state....</option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District Of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
<option value="GU">Guam</option>
<option value="PR">Puerto Rico</option>
<option value="VI">Virgin Islands</option>
</select></label>
<label for="Zipcode1">Zip Code:<input size= "10" type="text" name="Zipcode1" id="Zipcode1" onchange="check_zipcode('Zipcode1')"></label>
</div>
<div style="background-color:pink; width: auto; height: 22px; border:none; padding:0;">
<label for="Telephone1">Telephone Number:
<input size= "12" type="text" name="Telephone1" id="Telephone1" onchange="check_telephone('Telephone1')"> </label>
<label for="Telephone_type1">Home
<input type="radio" value="1" name="Telephone_type1" id="Telephone_type1" checked></label>
<label for="Telephone_type1">Work
<input type="radio" value="2" name="Telephone_type1" id="Telephone_type1"> </label>
<label for="Telephone_type1">Cell
<input type="radio" value="3" name="Telephone_type1" id="Telephone_type1"></label>
</div>
<div style="background-color:pink; width: auto; height: 15px; border:none; padding:0;">
<label for="Email1">Email:
<input type="text" size=40 onchange="check_email('Email1')" name="Email1" id="Email1"></label>
</div>
<div style="background-color:pink; width: auto; height: 27px; border:none; padding:0;">
<p>Have you filed these allegations of employment discrimination with another federal or local agency?</p>
</div>
<div style="background-color:pink; width: auto; height: 22px; border:none; padding:0;">
<label for="Allegations1">Yes<input type="radio" value="1" id="Allegations1" name="Allegations1" onchange="check_allegations('Allegations1')"></label>
<label for="Allegations2">No<input checked type="radio" value="2" id="Allegations2" name="Allegations1" onchange="check_allegations('Allegations2')"></label>
</div>
<div style="background-color:pink; width: 100%; height: 25px; border:none; padding:0;">
<label for="Agency_Name1">If yes, which agency:
<input size= "40" type="text" name="Agency_Name1" id="Agency_Name1" onchange="check_agency_name('Agency_Name1')"></label>
</div>
<div style="background-color:pink; width: auto; height: 22px; border:none; padding:0;">
<label for="Agency_POC1">Contact Name:
<input size= "23" type="text" name="Agency_POC1" id="Agency_POC1" onchange="check_name('Agency_POC1')"></label>
<label for="Agency_Telephone1">Phone Number:
<input size= "12" type="text" name="Agency_Telephone1" id="Agency_Telephone1" onchange="check_telephone('Agency_Telephone1')"></label>
</div>
</div>
<!-----------------
Foot
------------------>
<div style="background-color:white; width: 760px; height: 50px; border:none; padding:none;">
<footer>Form CC-4 (Revised 01/20XX)</footer>
</div>
</div>
</form>
</body>
</html>