Civil and Human Rights Complaint Form

Civil and Human Rights Complaint Form

National Association for Advancement of Colored People
New Jersey State Conference

4326 Harbor Beach Blvd.,

#775 Brigantine, NJ 08203

Phone #: 609-362-2496

Email: secretary@naacpnjsc.org
FOR OFFICE USE ONLY
PLEASE NOTE THAT WE WILL NOT PROCESS YOUR APPLICATION UNLESS ALL QUESTIONS ARE COMPLETED, ALONG WITH A ONE-PART SUMMARY OF THE ALLEGED DISCRIMINATION THAT OCCURRED.

INCOMPLETE APPLICATIONS WILL NOT BE INVESTIGATED.
Contact Information*
Address*
Email*
example@example.com
Are you a current member of the NAACP?*

YesNo
Branch Name:*
Unit #:*
Do you currently have an attorney?*

YesNo
Has a lawsuit been filed?*

YesNo
Date

MonthDayYear
Date
Have you. filed a complaint with the EEOC*

YesNo
Date

MonthDayYear
Date
Have you filed a complaint with Fair Employment & Housing?*

YesNo
Date

MonthDayYear
Date
Please list any agency against which you are filing complaint:*

Place of BusinessSchool DistrictGovernment AgencyLaw EnforcementOther
Indicate the type of discrimination:*

Civil Rights Violation/ Hate CrimeDiscriminationHarassmentHousingRacial ProfilingRetaliationOtherOther
How were you discriminated against?*
What would you like the NAACP to do for you?*
File Upload

Cancelof
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 New Jersey State Conference of the NAACP in seeking a remedy to the situation described above.

I hereby authorize the officers of the New Jersey State Conference 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 New Jersey State Conference WILL NOT BE RESPONSIBLE for handling this matter. In fact, I further understand that by signing this document, I am agreeing to HOLD the New Jersey State Conference harmless for any and all damages arising as a result of my case being mishandled, negligently handled, or improperly handled in any way.
Date*

MonthDayYear
Date
Name*

First NameLast Name
Signature*

Clear
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 New Jersey State Conference of the NAACP is ONLY seeking information to assist you concerning this complaint. You may upload documents (below) or send copies of sustaining documents or any other supporting information via email to secretary@njnaacp.org, or by mail in an envelope marked “Confidential” to:

NAACP New Jersey State Conference

4326 Harbor Beach Blvd., #775

Brigantine, NJ 08203
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