I affirm that the statements that I have made in this form are accurate and true to the best of my knowledge and belief. I hereby request the assistance of Unit #1119 of the NAACP in seeking a remedy to the situation described by me. I hereby authorize the officers of Unit #1119 to have access to information and documents which are relevant to my claim of discrimination described.
I understand that once a referral has been made to a volunteer, community agency or private attorney, Unit #1119 WILL NOT BE RESPONSIBLE for handling this matter. I further understand that by submitting this document I am agreeing to hold Unit #1119 of the NAACP harmless for any and all damages arising as a result of my case being mishandled, negligently or improperly handled in any way.
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, members or applicants for membership, because the employees, 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.
COMPLETION OF THIS FORM
Completing this form does NOT constitute filing an official complaint with a legal authority. At this time, unit #1119 of the NAACP is seeking information to assist you concerning this complaint. Please contact us at firstname.lastname@example.org
for more information.