NAACP Gwinnett County Branch

NAACP Gwinnett County Branch

Unit No. 5664
COMPLAINT FORM
Date of report:

MonthDayYear
Date
Please check the type of complaint that you are making:

Police MisconductEmploymentHarassmentCivil Rights violation/Hate crimesHousing/Public AccommodationsPublic TransportationBank/FinanceEducationOther
Please select the agency, organization and/or person of which you are filing the complaint against:

Place of BusinessEmployerSchool DistrictGovernment AgencyLaw EnforcementOther
Please provide the following information about yourself

PrefixFirst NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Work Location
(Place of Business) (Address) (Phone)
Do you currently have an attorney working in your behalf?

YesNoNot sure
**If yes, provide information below**
Attorney’s Name
Attorney’s Address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Has a lawsuit been filed?

YesNoNot sure
**If yes, when?**
In what city?
In what court?
mm/dd/yyyy
Have you filed an EEOC complaint?

YesNoNot sure
If yes, when filed?
Case #
Right to sue letter?

YesNoNot sure mm/dd/yyyy
Please include copies of filed complaints and right to sue letters upon submitting this completed form. If this is an employment complaint please complete the following about your employer and/or complainant.
A. Employer (or former employer)
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Supervisor’s Name
Business Agent/Steward
District
FieldBaseOffice
Time
Please check the box that best describes when the incident occurred.

BeforeDuringAfter Shift
Are you currently employed with this employer?

YesNo
Local Union’s Name
Local Union’s Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Local Union’s Telephone #

Area CodePhone Number
Fax #

Area CodePhone Number
Has a grievance or complaint been filed?

YesNoNot sure
If yes, what is the status of that grievance or complaint?

ClosedIn progressNot sure
Comments
Description of incident: (please copy form if more pages are needed)
B. For all other complaints please complete the following;
Who Discriminated against you?
Location of incident?
Description of incident
C. Witnesses to the incident
Name
Name
Address
Address
Phone
Phone
Occupation
Occupation
D. Describe what happened:
I, do hereby authorize the NAACP Legal Redress or Criminal Justice Committee to investigate my complaint and to take any steps necessary to resolve it, and I understand that the NAACP does not provide legal representation and that the organization has certain limitations as to the scope of their influence and ability.

Clear
(The NAACP, GA State Conference or Branch will make every effort to provide some degree of assistance to its members. If you are not a member, please contact the NAACP, GSC or the Branch.)
Current Member In Good Standing

YesNo
Paid Membership
Date
Legal Redress Chair or President Criminal Justice Chair.
Should be Empty:

NAACP Gwinnett County Branch

COMPLAINT FORM