LOS ANGELES NAACP DISCRIMINATION
COMPLAINT FORM
Print this form and mail or fax to: LOS ANGELES NAACP
P.O. Box 56408, Los Angeles, CA 90056
Phone (310) 397-1171 - Fax (310) 397-1179


                                           DATE________________________



NAME: ______________________________________________________________________



ADDRESS: ___________________________________________________________________



CITY: __________________________________ STATE: ______ ZIP: ________________



CONTACT TELEPHONE NUMBERS:      Residence (   )____-_________

                                     Work (   )____-_________
PLEASE CHECK THE TYPE OF COMPLAINT THAT YOU ARE MAKING:
        POLICE MISCONDUCT        (  )   EDUCATION            (  )

        EMPLOYMENT               (  )   HOUSING              (  )

        PUBLIC TRANSPORTATION    (  )   PUBLIC ACCOMODATIONS (  )

        BANKING & FINANCE        (  )   GOVERNMENT AGENCY    (  )

        RACE RELATIONS           (  )   VETERANS' AFFAIRS    (  )

        PRINT & ELECTRONIC MEDIA (  )   STAGE & THEATRE      (  )

        COMMUNITY RELATIONS      (  )   OTHER_______________ (  )

Do you currently have an attorney working in your behalf?  YES(  ) NO (  )



Attorney's Name ________________________________ Phone ____________________



Attorney's Address ___________________________________________ Zip ________



Has a lawsuit been filed? ____  When filed? _______________________________



In what city? _______________________ In what court? ______________________



Do you wish to file a civil or criminal appeal? ___________________________



Do you have financial resources? __________________________________________



Have you filed a complaint with the EEOC or Fair Housing & Employment? ___



If so, when? ___________ Do you have a "Right to Sue" letter issued by



either of these agencies? _________________________________________________



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



Employer (or former employer): _____________________________________________



Address ________________________________ City ______________ Zip ___________



Telephone ____________________________ Supervisor __________________________



Union ____________________________ Business Agent/Steward __________________



Local No. ________________________ Address _________________________________



____________________________________________________________________________



Has a grievance been filed through your union? _____________________________

Note:   The Los Angeles NAACP 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 the Los Angeles



NAACP to investigate my complaint and to take any steps necessary to



resolve it.



WITNESS____________________________ SIGNATURE __________________________



DATE ______________________________ MEMBERSHIP PAID $ __________________



Please attach a copy of the EEOC or Fair Housing & Employment complaint.

Internal Use Only

DATE RECEIVED _______________
REFERRED ____________________
DATE ________________________


DESCRIPTION OF INCIDENT:



____________________________________________________________________________



____________________________________________________________________________



____________________________________________________________________________



____________________________________________________________________________



____________________________________________________________________________



____________________________________________________________________________



____________________________________________________________________________



____________________________________________________________________________



____________________________________________________________________________



____________________________________________________________________________



____________________________________________________________________________



____________________________________________________________________________



____________________________________________________________________________



____________________________________________________________________________



____________________________________________________________________________



____________________________________________________________________________



____________________________________________________________________________



____________________________________________________________________________



____________________________________________________________________________



____________________________________________________________________________



____________________________________________________________________________



____________________________________________________________________________



____________________________________________________________________________


[HOME] [