NAACP/Alachua County Branch Complaint

Date:

Date

The Alachua County Branch of the NAACP does not provide legal assistance and is not acting as your attorney in this matter.

Name

Address

City

State

Zip Code

Cellphone

Format: (000) 000-0000.

Home Phone

Format: (000) 000-0000.

Work Phone

Format: (000) 000-0000.

Please check your type of complaint:

Do you already have an attorney working on your behalf?

YesNo

If yes, please complete the following:

Do you authorize your attorney to communicate with a representative from the Alachua County Branch NAACP? If yes, please initial here:

Attorney's Name:

Telephone:

Format: (000) 000-0000.

Address (City, State, Zip Code):

Has a lawsuit been filed?

YesNo

If yes, when was it filed?

In what city?

In which court?

Do you wish to file a civil or criminal appeal?

YesNo

Do you have financial resources?

YesNo

Have you filed a complaint with the any governmental agency?

YesNo

If yes, when and with which agency?

If this is an employment complaint, please provide the following information:

Employer or former employer:

Address:

Phone:

Format: (000) 000-0000.

Supervisor:

Union:

Business Agent/Steward:

Local Number:

Union Phone Number:

Format: (000) 000-0000.

Has a grievance been filed through your union?

YesNo

NAACP/Alachua County Branch

Alachua County NAACP Discrimination Complaint Form

FOR INTERNAL USE ONLY