Media Area Branch NAACP (Unit #2272) Complaint Form

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Please complete the attached Civil Rights & Discrimination Complaint form to assist the Branch's Legal Redress and/or Executive Committee(s) in determining whether the NAACP Media Area Branch may be able to assist you with your complaint. You are encouraged to provide copies of all supporting documentation that pertains to your complaint.

Completion of this form does not constitute filing an official complaint with a legal authority, such as filing a lawsuit or a complaint with a governmental agency. Nor does completing this form establish an attorney-client relationship between the NAACP Media Area Branch and the complainant. Our committee members are volunteers, often without legal backgrounds or experience.

We will investigate all complaints of discrimination that took place within our jurisdiction and can provide non-legal support to complainants (resources, guidance, help writing emails or letters, attendance at meetings, etc.).

Thank you for contacting the NAACP, Media Area Branch. Your activism
and support is greatly appreciated.

Respectfully,

Cynthia Jetter, President
Media Area Branch NAACP
NAACP Media Area Branch Civil & Human Rights Complaint Form

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.

IMPORTANT NOTICE

Please be advised that filing a discrimination complaint with the NAACP does not mean that the NAACP will be representing you in any legal matter. If you believe you have a discrimination claim, you must file a claim with the appropriate State or Federal agency in a timely manner. Failure to do so may prevent you from pursing a claim in a court of law.

COMPLETION OF THIS FORM

Completing this form does NOT constitute filing an official complaint with a legal authority. Currently the NAACP Media Area Branch is ONLY seeking information to assist you concerning this complaint. Please mail this information and copies of substantiating documents in an envelope marked "CONFIDENTIAL" to: Media Area Branch: Unit 2272, PO Box 1973, Media, PA, 19063-8973. You can also email the information and documents to mitch4319086@yahoo.com and cc: cynthiajetter59@gmail.com and dinanaacpsecmediaunit@gmail.com.

Email *

First and Last Name *

Mailing Address(include city, state, zip) *

Best Phone Number to Reach *

Best Time of Day to Contact by Phone

Description of Incident - Please provide all details. *

Date of Incident *

YYYY

Do you have an attorney working on your behalf? *

Yes

If have an attorney, please provide their contact info below including name, phone number and email.

What do you hope the Media Area Branch NAACP can do for you regarding this matter?
*

Release of Liability Disclosure: 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 Media Area Branch in seeking a remedy to the situation described above. I hereby authorize the officers of the NAACP Media Area Branch to have access to information and documents, which are relevant to my claim of discrimination described above. I understand that once a referral has been made to a volunteer, community agency or private attorney, the NAACP Media Area Branch WILL NOT BE RESPONSIBLE for handling this matter. I further understand that by signing this document, I am agreeing to HOLD the NAACP Media Area Branch harmless for any and all damages arising as a result of my case being mishandled, negligently handled, or improperly handled in any way. *

I acknowledge and agree with the Release of Liability Disclosure

I do not acknowledge or agree with the Release of Liability Disclosure

Required

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