Discrimination Complaint Form

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Thank you for your response. ✨

Date of Report (YYYY-MM-DD)

Date of Incident (YYYY-MM-DD)

Please check the type of complaint that you are making

Select the agency, organization and/or person of which you are filing the complaint against

Place of Business: Employer

Your First Name

Your Last Name

Mailing Address

Mailing Address Line 2

City

State

Email Address

Contact Number

Do you currently have an attorney working on your behalf?

Attorney’s First Name

Attorney’s Last Name

Attorney’s Mailing Address

City

State

Contact Phone Number

Has a Lawsuit been filed?

If yes, when filed? (YYYY-MM-DD)

Case Number?

Right to sue letter?

Have you filed a fair Employment and Housing complaint?

Comments

Description of Incident

What would you like the NAACP to do for you regarding the incident(s)?

I do hereby authorize the NAACP Legal Redress Committee to investigate my complaint and to take any steps necessary to resolve it, and I understand that the NAACP is not a legal entity and that the organization has certain limitations as to the scope of their Influence and ability.

RELEASE OF LIABILITY: (A) I affirm that the statements that I have made above are accurate and true to the best of my knowledge and belief. (B) I hereby request the assistance of the Santa Rosa – Sonoma NAACP in seeking a remedy to the situation described above. (C) I hereby authorize the officers of the Santa Rosa – Sonoma Branch Unit # 1074 to have access to information and documents, which are relevant to my claim of discrimination described above. (D) I understand that once a referral has been made to a volunteer, community agency or private attorney, the Santa Rosa – Sonoma NAACP Branch WILL NOT BE RESPONSIBLE for handling this matter. (E). In fact, I further understand that by signing this document, I am agreeing to HOLD the Santa Rosa – Sonoma NAACP Branch harmless for all damages arising as a result of my case being mishandled, negligently handled or improperly handled in any way.

NON-RETALIATION REQUIREMENTS: Section 704 (a) of the Civil Rights Act of 1964, (as amended), Section 4 (d) of the Age Discrimination in Employment Act of 1967, (as amended), and various other civil rights laws make it an unlawful employment practice for an employer; employment agency; or labor organization: to discriminate against employees, applicants for employment, member or applicant for membership, because the employee, member or applicant has opposed an unlawful employment practice, made a charge, testified, assisted, or participated in any manner in an investigation, proceeding or hearing.

COMPLETION OF THIS FORM: Completing this form does NOT constitute filing an official complaint with a legal authority. At this time the Branch is ONLY seeking information to assist you concerning this complaint. Please mail this information and copies of sustaining documents in an envelope marked “CONFIDENTIAL” to the Branch at PO Box 3964 | Santa Rosa, CA 95402

Type name for signature

Date of Signature (YYYY-MM-DD)

Discrimination Complaint Form

Thank you for your response. ✨

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