Civil Rights Complaint Form SBC-NJ NAACP
(FOR SBC-NJ NAACP TO INTERVENE, INCIDENT MUST HAVE OCCURRED IN ONE OF THE FOLLOWING TOWNS: BASS RIVER, CINNAMINSON, EVESHAM, LUMBERTON, MAPLE SHADE, MEDFORD, MEDFORD LAKES, MOORESTOWN, MOUNT LAUREL, PALMYRA, RIVERTON, SHAMONG, TABERNACLE, WASHINGTON TOWNSHIP)

(PLEASE NOTE THAT WE WILL NOT PROCESS YOUR APPLICATION UNLESS ALL QUESTIONS ARE COMPLETED, ALONG WITH A ONE-PART SUMMARY OF THE ALLEGED DISCRIMINATION THAT OCCURRED. INCOMPLETE APPLICATIONS WILL NOT BE INVESTIGATED.)
Sign in to Google to save your progress. Learn more
Name  (Last Name, First Name, Middle Initial) *
Address  (Street, City, State, Zip Code) *
Are you a current member of the Southern Burlington County NAACP Unit 2106? *
Telephone Number *
E-mail Address *
Do you currently have an attorney? *
Attorney Information  (Name, Telephone, Email, Address)
Has a lawsuit been filed? *
If the lawsuit has been filed, when was it filed?
Have you filed a complaint with EEOC? *
If you filed a complaint with EEOC, when was it filed?
Have you filed a complaint with Fair Employment & Housing? *
If you filed a complaint with Fair Employment & Housing, when was it filed?
Please select agency against which you are filing complaint *
Required
If Other, please list the agency against which you are filing complaint.
Indicate type of discrimination *
Required
Other type of discrimination
How were you discriminated against? *
Who discriminated against you?  Include name(s), race, and gender of each
Name, Race, Gender *
Name, Race, Gender
Name, Race, Gender
Where did the discrimination take place? (Address) *
Where did the discrimination take place? (Address)
Did anyone witness the discrimination that took place? *
Witness #1 (Name, Address, Phone, Email)
Are they willing to make statement on your behalf?
Clear selection
Witness #2 (Name, Address, Phone, Email)
Are they willing to make statement on your behalf:
Clear selection
What was the effect of the discrimination on you? *
To date, what actions have you taken so far? *
Is there any other organization or individual that you've filed a complaint with or notified regarding this matter?  (Name, Address, Phone, Email)
What actions, if any, were taken in response to the complaint or notice of concern?
Who took these actions?
When were these actions taken?
What would you like the NAACP to do for you regarding the discrimination? *
Supporting Documents
To provide supporting documents, please email them to sbcnaacpsecretary@gmail.com, and put "(Your Name) - Complaint Supporting Documents" in the email subject line.
Release of Liability
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 Southern Burlington County Branch of the NAACP in seeking a remedy to the situation described above.  I hereby authorize the officers of the SBC-NJ NAACP #2106 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 SBC-NJ NAACP Branch #2106 WILL NOT BE RESPONSIBLE for handling this matter.  In fact, I further understand that by signing this document, I am agreeing to HOLD the SBC-NJ NAACP Branch harmless for any and all damages arising as a result of my case being mishandled, negligently handled, or improperly handled in any way.


Signature (Constitutes as your electronic signature) *
Print Full Name
Date of Submission
MM
/
DD
/
YYYY
Disclaimer
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.
Completion of this form
Completing this form does not constitute filing an official complaint with a legal authority.  At this time, the SBC-NJ NAACP Branch is ONLY seeking information to assist you concerning this complaint. Thank you for your submission.
SBC-NJ NAACP
Southern Burlington County Branch NJ NAACP (Unit #2106)
PO Box 195 Marlton, NJ 08053
609-738-0103
sbcnaacpsecretary@gmail.com
www.sbcnaacp.org
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms