5001 First Avenue SE, #195,
Cedar Rapids, IA 52402

(319) 573-6617
IRS 501c3 #27-1408016
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In the name of ALLAH, Most Gracious, Most Merciful

Report an Incident

Please fill in your information:

Incident Date: Ex: 04/15/2005
First Name: * Last Name: *
Home Phone: * Work Phone:
Mobile Number: Fax:
Email Address: * Sex:
Title: Affiliation:
Street Address: City: *
State: * Zip Code:
Ethnic Background: Religion:
Filer Name:


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Please provide a detailed description of the incident below.  Include date, time, witnesses, and any evidence of religious discrimination:


Please fill in offending party's information:

 

Offender's First Name: Offender's Last Name:
Offender's Home Phone: Offender's Work Phone:
Offender's Mobile Number: Offender's Fax:
Offender's Email Address: Offender's Sex:
Offender's Title: Offender's Affiliation:
Offender's Street Address: Offender's City:
Offender's State: Offender's Zip Code:
*Required