DATE

Name

Address

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Daytime Phone Number

Evening Phone Number

E-mail Address

Do you currently have an attorney working on your behalf?   Yes   No

Attorney's Name   Phone 

Attorney's Address

Has a lawsuit been filed?  Yes   No

In what city?

In what court?

Do you wish to file a civil or criminal appeal?    Yes   No

Do you have financial resources?    Yes   No

Have you filed a complaint with the EEOC or Fair Housing & Employment?    Yes   No

Of so, when?

Do you have a "Right to Sue" letter issued by either of these agencies?    Yes   No

If this is an employment complaint, please provide the following information.

Address

City State State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Guam Northern Mariana Islands Puerto Rico US Virgin Islands Armed Forces Americas Armed Forces Europe Armed Forces Pacific ZIP Code

Phone Number

Supervisor

Has a grievance been filed through your union?    Yes   No

Union Business Agent/Steward

Local No. Address

Description on incident:

Note: NAACP Branch #1034 makes every effort to provide some degree of assistance to its members. If you are not now a member, please request a membership envelop now and join!!!

I, do hereby authorize NAACP Branch #1034 to investigate my complaint and to take any steps necessary to resolve it.

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