Employment Discrimination Complaint Form

Employment Discrimination Complaint Form

SECTION I


PLEASE READ AND ANSWER ALL QUESTIONS. DO NOT LEAVE ANY BLANKS!
being first duly sworn upon my oath affirm and hereby say: I have been given assurance by a representative of the FORT LAUDERDALE/BROWARD BRANCH OF THE NATIONAL ASSOCIATION FOR THE ADVANCEMENT OF COLORED PEOPLE (NAACP) that this Affidavit will be considered confidential by the NAACP and will not be disclosed as long as the case remains open unless it becomes necessary for the NAACP to produce the Affidavit in a formal proceeding. Upon the closing of this case, the Affidavit may be subject to disclosure in accordance with the policy of the Branch. 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.
In what Country were you born?

SECTION II


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COMPLAINT OF DISCRIMINATION NON-EMPLOYMENT RELATED INCIDENTS DETAILS

SECTION III


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(Give full name/s of the individual/s and their job titles; also, the name and address of the Employer, Labor Organization, Employment Agency, Apprenticeship Committee, Licensing Agency, and its owner, President/CEO’s name; etc. List/name all)
Detailed give detail information if different from the employer’s address

SECTION IV


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SECTION V


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Choose one

SECTION VI


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Choose one

SECTION VII


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Enter Employment date
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Choose one

SECTION VIII


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SECTION IX


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SECTION X


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(Please State Pertinent Information Only):

SECTION XI


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Choose one
Choose one

SECTION XII


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State Your Desired Results. Please Be Brief “To The Point” / “Specific.”

SECTION XIII


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I AFFIRM THAT I HAVE, ON MY OWN, MADE WRITTEN THE FOREGOING CHARGE AND HAVE HAD AMPLE OPPORTUNITY TO MAKE CORRECTIONS. ALSO, I AFFIRM THAT ALL OF THE INFORMATION AND STATEMENTS I SUPPLIED IN THIS COMPLAINT TO THE NAACP ARE FACTS, TRUE, AND CORRECT TO THE BEST OF MY KNOWLEDGE, INFORMATION, AND BELIEF. FURTHER, I AFFIRM THAT NONE OF THE AFOREMENTIONED IS OF FABRICATED OR FRIVOLOUS NATURE. IN CONSIDERATION OF SUCH DISCLOSURE, I HEREBY RELEASE AND HOLD HARMLESS THE NAACP AND ANY OF ITS REPRESENTATIVES FROM ANY AND ALL LIABILITY WHICH MAY ARISE THEREFROM.

By placing my initials to the left of each numbered item below and my signature at the end of this document, I affirm that I understand it and agree with it in full.

Respondent’s Name
If I do not file my complaint or lawsuit by that time, I may have no right to a recovery from any harm from the Respondent.
Print Name of NAACP Member/Volunteer
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