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
Fax (775) 322-9909
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
________________
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