Reno-Sparks NAACP Discrimination Complaint Form

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or download the document in Microsoft Word format
or download the document in .pdf format

 

Date

Name

Address

City

State

ZIP code

Contact telephone numbers
Residence (      )
Other (      )

Please state whom the complaint is against –

(Whom?)

(Where?) Address?

City

State

ZIP Code

An individual ____?
A business ____?
An employer ____?
Landlord/agent ____?
Realtor ____?
Governmental agency ____?
Law Enforcement ____?
Financial organization ____?
Educational organization ____?
Media ____?
Other ____?

(Why?) What was the basis for singling you out for different treatment?

National origin? ___

Color? ___
Citizenship? ___
Racial inference? ___
Sex? ___
Sexual preference? ___

Please explain:

 


(What?) What have you done to resolve your complaint against another?

Filed a complaint in writing with any other authority?

When?

Administratively?

How?

Have you had any results in pursuing your complaint to today's date?

When? Please give time, date and description of the incident that harmed you:

 

Please attach additional pages to describe the incident and any documents relating to your complaint.

If your complaint is with an employer (current or former), please provide the following additional information:

Employer

Address

City

State

ZIP code

Telephone (      )

Supervisor's name

Title

Union

Local

Business agent

Address

City

State

ZIP code

Has a grievance been filed with the union?

Do you currently have an attorney working in your behalf?
Yes ______
No ______

Attorney's name

Address

City

State

ZIP code

Has an administrative agency issued a "Right to Sue"?
Yes ______
No ______


Has a lawsuit been filed?
Yes ______
No ______

When and in which court?


I, (please print your name)

do hereby authorize the Reno-Sparks NAACP to investigate my complaint and to take any steps necessary to resolve my complaint.

Signed


Date


Witnessed by


Signed


Date

________________

NOTE: The Reno-Sparks NAACP makes every effort to provide assistance to its members. If you are not a member, please join by requesting a membership envelope or printing out this page: http://renosparksnaacp.org/docs07/tax.html


Please return the form to
Reno-Sparks NAACP
P.O. Box 7557
Reno, NV 89510
Phone (775) 322-2992

The NAACP cannot act without a written complaint

E-mail the Branch

http://renosparksnaacp.org


I, (please print your name)


hereby sign this release and disclaimer with the understanding that I will hold the NAACP harmless for any claim, liability or lawsuit.
I understand that the NAACP is a voluntary organization which has in no way agreed to provide me with legal counsel. I understand that it is my responsibility to seek legal counsel.

Signed


Date


Witnessed by


Signed


Date

________________

 

Internal Use Only
Date received:
Date referred:

 

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