Human Rights Tribunal of Ontario

Application to the Human Rights Tribunal of Ontario

Area of Discrimination: Goods, Services and Facilities Form !"#$
Note: #omplete this form if %ou believe %ou &ere discriminated against in the area of Goods, Services and Facilities'
Attach this form to %our Application'
Applicant(s )ame:

Respondents$ )ames$:


PART I
Questions About the Service, Goo or !acilit"
#$ *ut an +,+ beside the point that best describes the service, good or facilit% that this Application is based on'
-ncome support Store
.ducation / training Theatre
*olice services -nsurance
0edical1health services *ublic transportation
Sporting or other recreational facilit% Government, please describe: 222222222222222222
Retail Other, please describe: 222222222222222222

#% #omplete this section onl% if %our Application is about a practice or polic%'
Tell us &hat is the practice or polic% %ou are complaining about and e3plain ho& it relates to e4ual treatment &ith
respect to services, goods and facilities'

#& #omplete this section onl% if %our Application is about a la&'
Tell us &hat is the la& %ou are complaining about and e3plain ho& it relates to e4ual treatment &ith respect to
services, goods and facilities'

Questions About #om'laining to Someone in Authorit"
#omplete this section onl% if %ou complained to someone in authorit% about the alleged discrimination'
#( To &hom did %ou complain5

#) 6as there an investigation5 *es No +Go to Part II,
a, -f %ou ans&ered 78es9 to #:, &hat &as the outcome of the investigation5

30/06/08 Form 1-C Page 1 of 5
Human Rights Tribunal of Ontario
Application to the Human Rights Tribunal of Ontario
Area of Discrimination: Goods, Services and Facilities Form !"#$
PART II
The follo&ing *art as;s %ou to ans&er ho& %ou believe %ou &ere discriminated against based on grounds %ou
identified' -f %ou believe that %ou &ere discriminated against based on more than one ground, fill out all the sections
that appl%'
Questions About -iscrimination on the Grouns of Race, #olour, Ancestr", Place of Origin,
#iti.enshi', or /thnic Origin
#omplete this section onl% if %ou believe that %ou have been discriminated against on one or more of these grounds:
race, colour, ancestr%, place of origin, citi<enship, or ethnic origin'
#0 .3plain &h% %ou believe %ou &ere discriminated against because of %our race, colour, ancestr%, place of origin,
citi<enship, or ethnic origin'

#1 *lease describe ho& %ou identif% %ourself in terms of %our race, colour, ancestr%, place of origin, citi<enship, and
ethnic origin'

Questions About -iscrimination on the Groun of -isabilit" or Perceive -isabilit"
#omplete this section onl% if %ou believe that %ou have been discriminated against on the ground of disabilit% or
perceived disabilit%'
#2 .3plain &h% %ou believe %ou &ere discriminated against based on %our disabilit% or a perceived disabilit%'

#3 Do %ou have particular needs related to %our disabilit%5 *es No +Go to #$%,
a, -f %ou ans&ered 78es9 to #=, describe %our particular needs'

#$4 Did %ou as; the Respondents$ to meet %our needs5 *es No +Go to #$%,
a) -f %ou ans&ered 78es9 to #!>, describe &hat %ou as;ed the Respondents$ to do' -f %ou named more than
one Respondent, please tell us &ho %ou spo;e to'

#$$ Did the Respondents$ tr% to meet %our needs5 *es No +Go to #$%, -on5t 6no7 +Go to #$%,
a, -f %ou ans&ered 78es9 to #!!, describe &hat the Respondents$( did to meet %our needs' -f %ou named
more than one Respondent, please tell us &hat each did'

b, -f %ou ans&ered +8es+ to #!!, &h% do %ou believe the Respondents$ efforts to meet %our needs &ere not
enough5

30/06/08 Form 1-C Page 2 of 5
Human Rights Tribunal of Ontario
Application to the Human Rights Tribunal of Ontario
Area of Discrimination: Goods, Services and Facilities Form !"#$
Questions About -iscrimination on the Groun of -isabilit" or Perceive -isabilit"
#$% Do %ou plan to submit medical reports or documents
related to %our particular needs at the hearing5
*es No
a, -f %ou ans&ered 78es9 to #!?, please list the medical reports or documents here' 8ou do not need to send
copies at this time'

Questions About -iscrimination on the Groun of #ree +!aith, Religion or S"stem of
8eliefs,
#omplete this section onl% if %ou believe that %ou have been harassed or discriminated against on the ground of creed
faith, religion or s%stem of beliefs$'
#$& .3plain &h% %ou believe %ou &ere discriminated against based on %our creed'

#$( *lease describe %our creed'

Questions About -iscrimination on the Grouns of Se9, Pregnanc", Gener Ientit" or
Gener /9'ression
#omplete this section onl% if %ou believe that %ou have been discriminated against on the grounds of se3, pregnanc%,
or gender identit% or gender e3pression'
#$) -s %our Application about discrimination on the ground of
pregnanc%5
*es No
#$0 .3plain &h% %ou believe %ou &ere discriminated against based on %our se3, pregnanc%, or gender identit%'

#$1 *lease identif% %our se3 or describe %our gender identit% or gender e3pression'

Questions About -iscrimination on the Groun of Se9ual Solicitation, Se9ual Avances or
Re'risal for Refusing a Se9ual Solicitation or Avance
#omplete this section onl% if %ou believe that %ou have e3perienced se3ual advances or se3ual solicitation or reprisal
for refusing a se3ual solicitation or advance from someone &ho is in a position to grant or den% %ou a benefit'
#$2 Tell us &hat happened'

30/06/08 Form 1-C Page 3 of 5
Human Rights Tribunal of Ontario
Application to the Human Rights Tribunal of Ontario
Area of Discrimination: Goods, Services and Facilities Form !"#$
#$3 Ho& &as this person in a position to grant or den% a benefit5

Questions About -iscrimination on the Groun of Se9ual Orientation
#omplete this section onl% if %ou believe that %ou have been discriminated against on the ground of se3ual orientation'
#%4 .3plain &h% %ou believe %ou &ere discriminated against based on %our se3ual orientation'

#%$ *lease describe %our se3ual orientation'

Questions About -iscrimination or Harassment on the Grouns of !amil" or :arital Status
#omplete this section onl% if %ou believe that %ou have been discriminated against on the grounds of famil% or marital
status'
#%% .3plain &h% %ou believe %ou &ere discriminated against based on %our famil% or marital status'

#%& *lease describe %our famil% or marital status'

Questions About -iscrimination on the Groun of Age
#omplete this section onl% if %ou believe that %ou have been harassed or discriminated against on the ground age'
#%( .3plain &h% %ou believe %ou &ere harassed or discriminated against based on %our age'

#%) *lease give %our date of birth' DD10018888$

Question About Harassment or -iscrimination on the Groun of Association
#omplete this section onl% if %ou believe that %ou &ere discriminated against because the Respondents$ associated
%ou &ith a person &ho is a member of a group identified in the #ode'
#%0 *lease e3plain &h% %ou believe %ou &ere discriminated against because of association'

Questions About -iscrimination on the Groun of Re'risal
30/06/08 Form 1-C Page 4 of 5
Human Rights Tribunal of Ontario
Application to the Human Rights Tribunal of Ontario
Area of Discrimination: Goods, Services and Facilities Form !"#$
#omplete this section onl% if %ou believe that the Respondents$ have done something to punish %ou for e3ercising
%our rights under the Ontario Human Rights #ode'
#%1 *ut an +,+ in each bo3 that applies to %ou:
- claimed or enforced m% rights under the #ode Go to #?=$
- refused to infringe on another person@s rights under the #ode Go to #?=$
- started or too; part in a human rights proceeding Go to #?A$
#%2 -f %ou mar;ed that %ou started or too; part in a human rights proceeding in #?B, put an +,+ in each bo3 that
applies to %ou and give an% file numbers$'
The Ontario Human Rights #ommission OHR#$ OHR# File C: 2222222222222222222
The Human Rights Tribunal Of Ontario HRTO$ HRTO File C: 2222222222222222222
Other *roceeding D specif%:

#%3 *lease e3plain &h% %ou believe %ou &ere reprised against'

30/06/08 Form 1-C Page 5 of 5