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? _____________________________
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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.
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