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Discrimination Complaint Form
South Dade Branch South Dade NAACP
Discrimination Complaint Form
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Step
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DISCLAIMER: The South Dade Branch of the NAACP does not provide legal assistance and is not acting as your attorney in this matter.
Contact Information
Name
*
First
Last
Email Address
*
Cell Phone Number
*
Home Phone
*
Work Phone Number
Zip Code
Date / Time
Date
Time
Next: Discrimination Information…
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Please check your type of complaint:
Choose a Membership Plan
Police Misconduct
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Other
Tell Us About Your Complaint.
Do you already have an attorney working on your behalf?
*
No
Yes
Choose one
If yes, please complete the following: Do you authorize your attorney to communicate with a representative from the South Dade NAACP? Please initial here:
*
Clear Signature
Attorney Information
Name (copy)
*
First
Last
Address
Address Line 1
Address Line 2
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Has a lawsuit been filed?
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No
Yes
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When was it filed?
In which court?
Do you wish to file a civil or criminal appeal?
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Yes
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Do you have financial resources?
*
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Yes
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Have you filed a complaint with any governmental agency?
*
No
Yes
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If yes, when and with which agency?
Employment Complaints
Is this an employment complaint, please provide the following information:
*
No
Yes
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Employer or former employer:
*
Supervisor:
*
Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Employment Complaints
Has a grievance been filed through your union?
*
No
Yes
Choose one
Union:
Business Agent/Steward
Local Number:
Union Phone Number:
Complaint Sunmmary
Provide additional information regarding your incident
Provide additional information regarding your incident
Comments
Next: Complete & Submit (copy)
Click continue to complete your discrimination Complaint information and submit your form online.
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Acknowledgement & Form Submission
If you are not a member and you’re interested in becoming a member of South Dade NAACP, please complete our online form at: https://southdadenaacp.org/membership-form/
I,
*
do hereby authorize the South Dade branch of the NAACP to investigate my complaint and to take any steps necessary to resolve it. I understand that the South Dade Branch of the NAACP does not provide legal assistance and is not acting as my attorney in this matter.
Complaintant's Signature
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Print Full Name
Date / Time
Date
Time
Witness Signature
Clear Signature
Date / Time
Date
Time
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