|
FLINT BRANCH NAACP
DISCRIMINATION
COMPLAINT FORM
3455 Lippincott Boulevard
Flint, MI 48507-2027
Phone: (810) 742-8622
*Please print out form and mail it to the above address.
Thank You!
DATE________________________
NAME:
______________________________________________________________________
ADDRESS:
___________________________________________________________________
CITY: __________________________________ STATE: ______ ZIP:
________________
Email: _________________________________
CONTACT TELEPHONE NUMBERS: Residence ( )____-_________
Work ( )____-_________
PLEASE CHECK THE TYPE OF COMPLAINT THAT YOU ARE MAKING:
__POLICE MISCONDUCT
__ EDUCATION __ EMPLOYMENT
__ HOUSING __
PUBLIC TRANSPORTATION ( ) PUBLIC ACCOMMODATIONS ( )
BANKING & FINANCE ( ) GOVERNMENT AGENCY ( )
RACE RELATIONS ( ) VETERANS' AFFAIRS ( )
PRINT & ELECTRONIC MEDIA ( ) STAGE & THEATRE ( )
COMMUNITY RELATIONS ( ) OTHER_______________ ( )
Do you currently have an attorney working in your behalf? YES (
) NO ( )
Attorney's Name ________________________________ Phone
________________
Attorney's Address ___________________________________________
Zip ________
Has a lawsuit been filed? ____ When filed?
_______________________________
In what city? _______________________ In what court?
______________________
Do you wish to file a civil or criminal appeal?
___________________________
Do you have financial resources?
__________________________________________
Have you filed a complaint with the EEOC or Fair Housing &
Employment? ___
If so, when? ___________ Do you have a "Right to Sue" letter
issued by
either of these agencies?
_________________________________________________
If this is an employment complaint, please provide the following
information.
Employer (or former employer):
_____________________________________________
Address ________________________________ City ______________ Zip
___________
Telephone ____________________________ Supervisor
__________________________
Union ____________________________ Business Agent/Steward
__________________
Local No. ________________________ Address
_________________________________
____________________________________________________________________________
Has a grievance been filed through your union?
_____________________________
Note: The Flint Branch NAACP makes every effort to provide some
degree
of assistance to its members. If you are not now a member,
please request a membership envelop now and join!!!
I, ________________________________ Do hereby authorize the
Flint Branch
NAACP to investigate my complaint and to take any steps
necessary to resolve it.
WITNESS____________________________ SIGNATURE
__________________________
DATE ______________________________ MEMBERSHIP PAID $
__________________
Please attach a copy of the EEOC or Fair Housing & Employment
complaint.
Internal Use Only
DATE RECEIVED _______________ REFERRED ____________________
DATE ________________________
DESCRIPTION OF INCIDENT:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
| 
