Click here for a copy  of the EEOC form in a new window. Then return to this page.

Print and make a copy for your records. Sign, date, and write across the top:

I intend for my complaint to be combined with Charge Number: 541-2011-01769

Sample instructions for EEOC document

1. Personal information

2. United AirLines, 77 W. Wacker Drive, Chicago, IL 60601 ph: (312) 997-8000

Business - Airline

HR VP: Michael P Bonds (312)997-2915

More than 500 employees

3. Hire date and job title (Optional)

Job title at time of discrimination: Retired

4. Age

5. A. Today's date your words - guidance:

United AirLines is taking away existing retiree travel benefits while improving travel benefits for younger employees.

Retirement travel benefits were part of our new hire benefit package, were contractual, were improved as a reward for financial sacrifice in dire times, and were always implemented at retirement.

B. N/A

6. Your comments go here.

EXAMPLE: The new retiree plan decimates existing benefits of older people while younger employees receive improvements.

7. If appropriate

8. Better than: Executive Officers and members of the Board of Directors

Worse than: None

Same: 37,000 unnamed United retirees

13. 37,000 unnamed retirees who do not even know about the change in their benefits

14. No

16. Have you?

Box 2 is appropriate

Print and make a copy for your records. Sign, date, and write across the top:

I intend for my complaint to be combined with Charge Number: 541-2011-01769

Mail to: Equal Employment Opportunity Commission

Atten: Myrna DeQuiroga, Intake Supervisor

303 East 17th Street, Ste. 410

Denver, CO 80203