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Gloucester County NAACP
Thank you for contacting the Gloucester County NAACP. Please complete the questions below. Try to answer all the questions clearly and with as much detail as possible. If a question does not apply to you, mark N/A.
After your complaint has been reviewed we will contact you within 5 business days to gather any additional information or notify you of how we will proceed.
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Your full name
Your answer
Phone number
Your answer
Email
Your answer
I am submitting this complaint on behalf of:
Myself
Biological child
Legal Dependant (ex. foster or step-child)
Spouse
Parent
Other:
Clear selection
Basis of Discrimination:
Choose
Age
Affectional/Sexual Orientation
Ancestry
Color/Nationality/Race
Creed
Disability
Domestic Partnership Status
Familial Status
Gender Identity or Expression
Liability for Military Status
Marital/Civil Union Status
Religion
Sex/Gender (including pregnancy)
Sexual Harassment
Other
Name of people or parties involved and what their relationship to you. Ex: Mark Thomas-Son
Your answer
Town and county in which you live.
Your answer
Town and county in which the alleged incident occurred.
Your answer
Does this incident involve anyone under 18 years old?
Yes
No
Not sure
Clear selection
Explain why you feel you or the person you are completing this form for has been discriminated against.
Your answer
Has this incident been reported to anyone? Ex: School principal, Law enforcement, Lawyer, etc.
Your answer
If appropriate, as determined by our board, are you willing to resolve your complaint through mediation or another alternative dispute resolution process?
Your answer
Name of person or organization you believe has discriminated?
Your answer
Date of the initial alleged discrimination.
MM
/
DD
/
YYYY
Provide any additional dates below.
Your answer
Name and contact information of the people involved.
Your answer
Name and contact information of anyone who may have witnessed the alleged discrimination or is willing to support/clarify the allegations.
Your answer
What remedy or resolution are you seeking?
Your answer
Have you file a discrimination complaint with the
NJ Division of Civil Rights
US Equal Opportunity Commission
Both
No
Clear selection
Submit
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