richmond branch naacp discrimination complaint form1 by HC12110614187

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									                            Richmond Virginia Branch NAACP
                                    416 North 2nd St., Richmond, Va. 23219
                                          Phone: 804-644-9337

                                 Discrimination Complaint Form
          Based on Race, Color, Religion, National Origin, Sex, Age and Handicapped Status


Completing this form does not constitute filling an official complaint with a legal authority. At this time, the NAACP
is only seeking information to assist you concerning this complaint. We only address incidents that occurred in the City of
Richmond. .

Please Print or Type

Your Name _________________________________________________ Phone (____) ________________

Street Address _____________________________________________________________________________________

City __________________________________________              State ___________ Zip _______________________

Email: __________________________________________________________

Please indicate the nature of the discrimination (circle those applicable) and include date of incident.

         Education: (Suspension. Racial... incident, Competency Exam)
         Employment: Hiring, Promoter. Job Assignment, Training
         Public Accommodations/Services: Store, Hotel
         Police Action: Harassment, Brutality, other
         Race, National Origin, Sex, Religion, Handicap, Age, Political Affiliation, Sexual Harassment,
          Personal Injury, Housing, or Other, please explain

Please include other information (use: additional sheets if necessary) and attach any supporting documents.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

What have you done to resolve this complaint?




Note: The filing of this complaint does not obligate the NAACP in any matter. It is your responsibility to pursue
your complaint in the appropriate manner.

I AFFIRM THAT THE INFORMATION I HAVE PROVIDED IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.

____________________________________________                                  ________________________________
        Signature of Complainant                                                                  Date
                                                                                                       NAACPFormCol1lplaint

								
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