NAACP-GWINNETT-Complaint-FORM

Gwinnett County Complaint Form

First Name*

Last Name*

Email*

example@example.com

Phone Number*

Area CodePhone Number

Your Race

Discrimination occurred as a result of:

How were you mistreated, harassed, or discriminated against

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

Have you ever filed a complaint with or notified any other organizationindividual regarding this issue?*

YesNo

Anything else you would like to add?

RELEASE OF LIABILITY
I affirm that the statements that I have made above are accurate and true to the best ol my knowledge and belief. I hereby request the assistance of the NAACP Gwinnett County Branch in seeking a remedy to the situation described above. I hereby authori2e the ofl1Cers ol the NAACP Gwinnett County Branch to have access to information and documents, which are relevant to my claim of discrimination descnbed above. I understand that once a referral to a volunteer, community agency, or pnvate attorney has been made, the NAACP Gwinnett COUNTY BRANCH Will NOT BE RESPONSIBLE IOI' handling this matter. In tact, I further understand that by submitting this document. I am agreeing to HOLD the NAACP Gwinnett COUNTY BRANCH harmless for any and all damages arising as a result ol my case being mishandled, negligently handled. or improperly handled in any way.

NON-RETALIATION REQUIREMENTS
Section 704 (a) ol the Civil Rights Act ol 1964. (as amended), Section 4 (d) ol the Age Discrimination in Employment Act ol 1967, (as amended), and various other civil nghts laws make it an unlawful employment practice tor an employer: employment agency: or labor organization: 10 discriminate against employees, applicants for employment, member or applicant !or membership. because the employee, member or applicant has opposed an unlawful employment practice. made a charge, tesblied, assisted, or participated in any manner in an investigation, proceeding or hearing.

COMPLETION OF THIS FORM
Completing this lorm does not constitute lihng an official complaint with a legal authority. At this time the State Ot Georgia NAACP is only seeking mlormabon to assist you concerning this complaint. Please send this information and copies of sustaining documents in an envelope marked confidential to:
State ol Georgia NAACP 2001 Martin Luther King Jr. Drive, Suite 307, Atlanta, Georgia 30310