Community Complaint Intake Form
Submit your complaint to the NAACP Victor Valley Branch #1082. An Intake Team Member will contact you after review to schedule an appointment with the appropriate committee.
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Preferred Method of Contact
*
Phone
Email
Either
Mailing Address (optional)
What type(s) of issue are you reporting? (Check all that apply)
*
Education Discrimination
Racial or Ethnic Discrimination
Health-Related Discrimination
Civil Rights Violation
Housing Discrimination
Employment Discrimination
Police Misconduct / Use of Force
Public Accommodation Discrimination
Other (please describe below)
If 'Other', please describe the type of issue:
Date(s) of Incident
*
-
Month
-
Day
Year
Date
Time(s) of Incident (if known)
Location of Incident
*
Please describe the complaint in detail, including who was involved, what happened, what was said or done, and any steps you have already taken to address the issue.
*
Do you have documents, photos, emails, screenshots, or other evidence related to this complaint?
*
Yes
No
Upload supporting documents (if applicable)
Upload a File
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of
Acknowledgment
*
I understand that this is an intake form only and does not create a legal client relationship. I understand that the NAACP Victor Valley Branch #1082 will review my information, and that once processed, an NAACP Intake Member will schedule an appointment with the appropriate committee to review and address my issue.
Any final comments or information you would like to add?
Submit Complaint
Should be Empty: