First Name*	Last Name*
Home phone*	Business Phone

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Address 1*	Address Continued
City/Town*	County
State* AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming	Zipcode*

First Name*	Last Name*
Home phone*	Email*

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Address 1*	Address Continued
City/Town*	County
State* AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming	Zipcode*

Nature of Complaint

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Explanation of Complaint

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Do You Believe You Were Discriminated Against Because of?

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Are You Aware of Other Individuals Who May Have Been Subjected To The Alleged Discriminatory Conduct? If Yes, Provide Names, Addresses, And Telephone Numbers, If Possible

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What Remedy Are You Seeking?

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Have You Sought Or Received Assistance From The Equal Employment Opportunity Commission Or Any Other Agency? If Yes Provide Names, Addresses, And Telephone Numbers, If Possible

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Are You Represented By A Private Attorney? If Yes, Provide Name, Address, And Telephone Number

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Is A Court Action Pending? If Yes, Provide Case File Number And A Copy Of The Complaint

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NOTE: This complaint form is NOT the equivalent of filing a formal charge with the Equal Employment Opportunity Commission (EEOC).

In filing this complaint, I understand that the NAACP is not my private attorney, but assists the public with information/investigation/conciliation/attorney referral with respect to laws designed to protect the public from patterns and practices of discrimination or discriminatory policies. I also understand that this complaint form is not a lawsuit, but rather an informal preliminary summation to obtain guidance on my belief that I have been discriminated against. I understand that the NAACP may use its discretion to determine whether an investigation is warranted and may need to contact the person/entity I am complaining about. This serves as authority to make such contact and obtain any information, personal or confidential. I retain the right to contact a private attorney. NAACP may refer me to a private attorney and may communicate with the attorney on my behalf. The above complaint is true and accurate to the best of my knowledge. I also understand that any false statement made in this complaint is grounds for the NAACP to refuse further assistance and may make disclosure to proper authorities.

Click the check box to Agree with the above statements.*

NAACP Member ?* YesNo

Registered Voter ?* YesNo