CAIR Minnesota

Date of Incident DATE *

Type of case: Employment FBI/Police DHS Airport/CBP/TSA

Did the incident happen to you or are you contacting us on behalf of another? Happened to me/Happened to another

If it happened to another please provide their name:

Home Phone:

Cell Phone:

Work Phone:

Best number to reach you:

Email:

Mailing Address:

Gender: Male Female

Religion:

Ethnicity:

Has any other group or person been contacted to help you in this matter? Y/N Yes No

If yes, name who:

Do you have an attorney for this matter? Yes No

Name:

Title:

Company:

Phone:

Address: