NAACP GWINNETT Complaint

Gwinnett NAACP Complaint Form

Enter Today's Date

First Name*

Last Name*

Email*

Confirmation Emailexample@example.com

Phone Number*

Are you a NAACP member?*

YesNo

Your Race*

Gender*

What is the nature of your complaint?*

Please describe your complaint:*

By whom were you mistreated? Name, Position, Company or Institution*

What type of resolution or assistance are you seeking from the Gwinnett NAACP regarding your complaint?*

Have you ever filed a complaint with or notified any other organization regarding this issue?*

YesNo

If you answered "yes" to the previous question. Please list the name of the organization below.

Do you have an Attorney?

YesNo

If you answered "yes" to the previous question. Please list the name, email address, and telephone number of your Attorney.

Has a lawsuit been filed?

YesNoNot Sure

Anything else you would like to add?

RELEASE OF LIABILITY

I affirm that the statements I have made above are accurate and true to the best of my knowledge and belief. I hereby request the assistance of the Gwinnett County NAACP in seeking a remedy for the situation described above. I hereby authorize the officers of the Gwinnett County NAACP to have access to information and documents relevant to my claim of discrimination described above.

I understand that once a referral to a volunteer, community agency, or private attorney has been made, the Gwinnett County NAACP will NOT be responsible for handling this matter. Furthermore, I understand that by submitting this document, I agree to HOLD the Gwinnett County NAACP harmless for any and 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, members, or applicants 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 Gwinnett County NAACP is only seeking information to assist you concerning this complaint. Please send this information and copies of supporting documents in an envelope marked "Confidential" to:

Gwinnett County NAACP
Po Box 1207
Lawrenceville, Georgia 30046

Signature*