Civil Rights Complaint Form
For Willingboro & Vicinity NAACP to intervene, the incident must have occurred in one of the following New Jersey communities: Beverly, Burlington City, Burlington Township, Delanco, Delran, Eastampton, Edgewater Park, Florence, Hainesport, Mt Holly, Riverside, Westampton or Willingboro.
NOTE: Your application will not be processed unless all questions are completed, along with a one-part summary of the alleged discrimination that occurred. Incomplete applications will not be investigated.
Street Address Line 2
State / Province
Postal / Zip Code
Please enter a valid phone number.
Are you a current member of Willingboro & Vicinity NAACP Unit #2111
Do you currently have an attorney?
Attorney Information (Name, Address, Telephone & Email)
Has a lawsuit been filed?
If the lawsuit has been filed, when was it filed?
Have you filed a complaint with EEOC?
If you filed a complaint with EEOC, when was it filed?
Have you filed a complaint with Fair Employment & Housing?
If you filed a complaint with Fair Employment & Housing, when was it filed?
Select agency against which you are filing complaint.
Place of business
If Other, please list the agency against which you are filing complaint.
Indicate type of discrimination.
Civil Rights Violation/Hate Crime
If Other, please describe the type of discrimination.
How were you discriminated against?
Who discriminated against you? Include name(s), race, and gender of each.
Name, Race, Gender
Name, Race, Gender
Name, Race, Gender
Where did the discrimination take place? (Address)
Did anyone witness the discrimination that took place?
Witness #1 (Name, Address, Telephone & Email)
Will they (Witness #1) make a statement on your behalf?
Witness #2 (Name, Address, Telephone & Email)
Will they (Witness #2) make a statement on your behalf?
What was the effect of the discrimination on you?
To date, what actions have you taken so far?
Is there any other organization or individual that you've filed a complaint with or notified regarding this matter? (Name, Address, Telephone & Email)
What actions, if any, were taken in response to the complaint or notice of concern?
Who took these actions?
When were these actions taken?
What would you like the NAACP to do for you regarding the discrimination?
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Release of Liability
I affirm that the statements that I have made above are accurate and true to the best of my knowledge and belief. I hereby request the assistance of the Willingboro & Vicinity Branch of the NAACP in seeking a remedy to the situation described above. I hereby authorize the officers of the Willingboro & Vicinity Branch of the NAACP #2111 to have access to information and documents which are relevant to my claim of discrimination described above.
I understand that once a referral has been made to a volunteer, community agency, or private attorney, the Willingboro & Vicinity Branch of the NAACP #2111 WILL NOT BE RESPONSIBLE for handling this matter. In fact, I further understand that by signing this document, I am agreeing to HOLD the Willingboro & Vicinity Branch of the NAACP harmless for any and all damages arising as a result of my case being mishandled, negligently handled, or improperly handled in any way.
Signature (Constitutes as your electronic signature)
Print Full Name
Date of Submission
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 Willingboro & Vicinity Branch of the NAACP #2111 is ONLY seeking information to assist you concerning this complaint. Thank you for your submission.
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