Complaint Form

First Name *

Address

State

Phone

Last Name *

City

Zipcode

Who discriminated against you? ((Give name and address of the employer, Labor Organization, Employment Agency, Etc.) *

Have you filed a complaint with any governmental agency? (If so, enter the name and date filed) *

Have you filed a grievance with your union? (If yes, enter name of local and representative) *

List the actual date of most recent date on which this discrimination occurred. (MM/DD/YYYY and time) *

Explain what was done to you: (contact us to provide further details and supporting documents) *

What resolution are you seeking? *

Have you retained an attorney regarding this case that we can contact? *

Yes

If you answered yes, please provide attorney's information:

9. I affirm that I have read the above charge and that it is true to the best of my knowledge, information and belief. I authorize the local branch of the NAACP to investigate my complaint. I understand that the NAACP is not a law firm and that it cannot provide me legal advice or provide legal representation; therefore, I am not precluded from seeking legal representation in this matter.

Name of Complainant *

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Complaint Form

YJCW NAACP Branch