NATIONAL ASSOCIATION                                    COMPLAINT OF                                                     

FOR THE ADVANCEMENT                                  DISCRIMINATION



                                    Based on race, color, religion, national origin, sex, age, handicapped status


Please Note: Completing this form does not constitute filing an official complaint with a legal authority.

At this time, the NAACP is only seeking information to assist you concerning this complaint..


                     MAIL, FAX OR DELIVER TO NAACP UNIT:              Kansas City, Missouri NAACP Branch

                                    1601 East 18th Street, Suite 212

                                                        Kansas City, Missouri 64108

(Please Print or Type)                                                    Tel: 816-421-1191    Fax: 816-421-4939




Your Name:                                                                                                                   Phone Number:


Street Address:


City:                                                                                                                State:                                 Zip:




Was the discrimination because of: (Please check those that apply)





















Who discriminated against you?  Give name, address and contact number of the Employer, Labor Organization, Employment Agency, Apprenticeship Committee, Licensing Agency, etc.  (List All)

Name: _______________________________________________ Contact #: ___________________________________


Street Address: ____________________________________________________________________________________


City:___________________________________________ State: ____________ Zip Code:_________________________


And other parties (if any): _____________________________________________________________________________



Have you filed a complaint with any governmental agency (ies)? If so, which one(s)?






Have you filed a grievance with your union?           





Name of Local Representative: ______________________________________________________________




Have you retained an                   Name of Attorney: ______________________________________________________________________

attorney regarding this case?         Address: ______________________________________________________________________________





   No                              Phone: _______________________________________________________________________________



The actual date or the most                 Month: ________________ Day: ________ Year: ______________

recent date on which this                    

discrimination occurred:                     Time of Day: ____________________________________________





Explain what unfair thing was done to you: (Attach additional sheets of paper if you need more space)










I affirm that I have read the above charge and that it is true to the best of my knowledge, information and belief.


(Signature of Complainant)____________________________________________________        (Date) __________________              










Kansas City, Missouri NAACP Branch

1601 East 18th Street, Suite 212

Kansas City, Missouri 64108

Tel: 816-421-1191         Fax: 816-421-4939


Prepared by the Labor Department of the NAACP

For more information contact the Labor and Industry Committee of the NAACP unit in your community.


Answer all questions and be as specific as possible. These directions are numbered to match the questions on the Complaint of Discrimination form.


Question 1: Be sure to give your full name, address    

   and phone.  If you do not have a phone, give a

   phone number where you can be reached.

Question 2: Please check the box that indicates  

   What you believe to be the cause of

   discrimination. If other, please state what

   violation of your civil rights has occurred.

Question 3: If you believe that other parties (for

   example, a labor union or any employment

   agency, in addition to an employer) were involved

   in the act of discrimination, list them on the last

        line of section 3.

Questions 4,5 & 6: If you have consulted an

   attorney or filed this complaint with a state or

   local human relations/rights commission, Federal

   government, union or agency, check “yes” and

   give the name.

Question 7: Give the day, month and year of the

   most recent date the discrimination took place. In

   some instances, the discrimination may be

   continuing for example, seniority lines are


Question 8: Tell us as much as you can.  For

   example: Were you fired? Did you fail to get a

   promotion? Did the company refuse to hire you?


   Did the union or employment agency refuse to

   refer you to a job? Who discriminated against

   you? Why do you believe it was because of your

   race, color, religion, national origin, sex, age or


Question 9: Sign your name, and mail, fax or take to the  

   NAACP office listed above.





        NAACP units should refer complainants alleging employment discrimination to an appropriate agency for official investigation, i.e. EEOC, State or Local Human Rights Commission.  Labor and Industry Committees of local NAACP units are further encouraged to forward the information on this form to an appropriate agency and to monitor the agency’s work on all cases referred by the NAACP.  To the extent resources allow, NAACP units may provide other supportive assistance to the complainant.


   In virtually all instances of employment discrimination, complainants will lose their right to any form of legal remedy if they do not file a complaint with the EEOC within 180 days of the event of the alleged discrimination.  If your state has a human or civil rights commission, then this time period is expanded to 300 days.  If there is any doubt, file within 180 days to be sure.


   Determine if the complainant is a member of the unit and/or Association.