(Form Sample)
DISCRMINIATION
COMPLAINT FORM
Victor
Valley Branch No. 1082
PO
Box 1563
Victorville, CA 92393-1563
NAACP
MISSION STATEMENT
The mission of the National Association for the Advancement of Colored People is to ensure the political, educational,
social and economic equality of rights of all persons and to eliminate racial hatred and racial discrimination.
LAST NAME________________________ FIRST NAME________________________MI______DATE_____________
ADDRESS________________________________ CITY_________________________
STATE________ ZIP__________
CONTACT TELEPHONE NUMBERS: RESIDENCE: ( ) _______________
WORK: ( )
_______________
PLEASE
CHECK THE TYPE OF COMPLAINT THAT YOU ARE MAKING:
BANKING AND FINANCE ( ) POLICE MISCONDUCT
( )
BUSINESS & TRADE
( ) PRINT
& ELECTRONIC MEDIA ( )
COMMUNITY RELATIONS ( ) PUBLIC
ACCOMODATIONS
( )
EDUCATION
( ) PUBLIC
TRANSPORTATION
( )EMPLOYMENT
( ) RACE RELATIONS
( )
GOVERNMENT AGENCY ( )
OTHER______________( )
HOUSING ( )
Do you currently have an attorney working in your behalf? Yes
( ) No ( )
Attorney’s Name_________________________________________
Phone_______________________________________
Attorney’s Address______________________________
City__________________________ State_____ Zip__________
Has a lawsuit been filed?______ If
yes, When was it filed?___________ In what city and court?____________________
Do you wish to file a civil or criminal
appeal?_______________ Do you have financial resources?__________________
Have you filed a complaint with the
EEOC or Fair Housing & Employment?___________ If so, when?_____________
Do you have a “Right to Sue”
letter issued by either of these agencies?_______________
***If
this is an employment complaint, please provide the following information***
Employer (or former employer):________________________________________________________________________
ADDRESS________________________________ CITY_________________________
STATE________ ZIP__________
Supervisor’s Name___________________________________
Telephone Number________________________________
Union_______________________________________Business
Agent/Steward___________________________________
Local Union No.________________ Adress________________________________________________________________
Has a grievance been filed through
your union?____________________________________________________________
Note: The Victorville NAACP Branch make every effort to provide some
degree of assistance to its members. I f you are not now a member, please request
a membership envelop now and join!!!
I, ___________________________________________________
do hereby authorize the Victorville NAACP Branch to
investigate my complaint and to take
any steps necessary to resolve it.
Signature____________________________ Date_______________
Witness_____________________________
Date_______________
Membership Paid $___________________
***PLEASE
ATTACH ANY COPIES OF EEOC OR FAIR HOUSING & EMPLOYMENT COMPLAINTS***
DESCRIPTION
OF INCIDENT BEING REPORTED TO NAACP
