Discrimination Complaint Form

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706.527.2272
service@naacptroup.org

Discrimination Complaint Form

    First Name *

    Last Name *

    Your email *

    Phone *

    Date of Incident *

    Location of Incident * (NOTE: If your incident did not take place in Troup County, Georgia, your information will be sent to the appropriate NAACP branch.)

    Did the discrimination occur as a result of *

    Other Discrimination (please specify):

    How were you mistreated, harassed, or discriminated against *

    Type of Discrimination: *

    Other Type (please specify):

    How were you mistreated, harassed, or discriminated against *

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

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

    Name and Contact Information of other organization or person *

    What do you hope the Troup County NAACP can do for you regarding this matter? *

    Please review RELEASE OF LIABILITY statements before submitting

    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 NAACP TROUP County Branch in seeking a remedy to the situation described above. I hereby authorize the officers of the NAACP TROUP County Branch to have access to information and documents, which are 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 NAACP TROUP COUNTY BRANCH WILL NOT BE RESPONSIBLE for handling this matter. In fact, I further understand that by submitting this document, I am agreeing to HOLD the NAACP TROUP COUNTY BRANCH harmless for any and all damages arising as a result of my case being mishandled, negligently handled, or improperly handled in any way.

    IMPORTANT NOTICE

    I understand that filing a discrimination complaint with TROUP NAACP does not mean that the NAACP will be representing me in any legal matter. If I believe I have a discrimination claim, I know I must file a claim with the appropriate State or Federal agency in a timely manner. I understand failure to do so may prevent me from pursuing a claim in a court of law.

    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, 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 TROUP County Branch is only seeking information to assist you concerning this complaint. You can mail this information and ALL COPIES of sustaining documents in an envelope marked confidential to: NAACP TROUP County Branch.