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Discrimination Complaint Form
South Dade Branch South Dade NAACP
Discrimination Complaint Form
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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
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*
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Last
Email Address
*
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*
Home Phone
*
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Date / Time
Date
Time
Next: Discrimination Information…
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Tell Us About Your Complaint.
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*
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Yes
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If yes, please complete the following: Do you authorize your attorney to communicate with a representative from the South Dade NAACP? Please initial here:
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Has a lawsuit been filed?
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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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Do you have financial resources?
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Have you filed a complaint with any governmental agency?
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Yes
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If yes, when and with which agency?
Employment Complaints
Is this an employment complaint, please provide the following information:
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Yes
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Employer or former employer:
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Supervisor:
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Address
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Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
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Washington
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State
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Employment Complaints
Has a grievance been filed through your union?
*
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Yes
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Union:
Business Agent/Steward
Local Number:
Union Phone Number:
Complaint Sunmmary
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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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Date / Time
Date
Time
Witness Signature
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Date / Time
Date
Time
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