Legal Redress Legal RedressLast NameMiddle InitialFirst NameEmail Address:Phone Number:PLEASE NOTE THAT WE WILL NOT PROCESS YOUR APPLICATION UNLESS ALL REQUIRED QUESTIONS ARE COMPLETED, ALONG WITH A DETAILED SUMMARY OF THE ALLEGED DISCRIMINATION THAT OCCURRED. INCOMPLETE APPLICATIONS WILL NOT BE INVESTIGATED. Do you currently have an attorney? Yes NoAttorney's Name:Attorney's Phone Number: Has a lawsuit been filed? Yes NoIf yes, when?Have you filed a complaint with the EEOC? Yes NoIf yes, when?Have you filed a complaint with Fair Employment & Housing? Yes NoIf yes, when?Please select the type of entity/organization you are filing complaint against: Place of Business Government Agency School District Law Enforcement OtherIf you selected other, please list the type of entity/organization below:Type of Discrimination: Civil Rights Violation / Hate Crimes Discrimination Harassment Housing Racial Profiling Retaliation OtherIf you selected other, please explain below:Please provide a summary of how you were discriminated against:By whom were you discriminated? Please include name(s), race, and gender of each:Where did the discrimination take place? Cite location/address for each incident:Did anyone witness the discrimination take place? Yes NoWitness #1 - Please list any information you have for this individual (Name, Phone Number, Address, etc)Is this person willing/available to make a statement on your behalf? Yes NoWitness #2 - Please list any information you have for this individual (Name, Phone Number, Address, etc)Is this person willing/available to make a statement on your behalf? Yes NoWhat effect or impact has the discriminating behavior had on you?To date, what actions have you taken so far?Have you filed a complaint with or notified any other organization or individual regarding this matter? Yes NoPlease list any organizations or individuals you've notified or filed complaint with, including Name, Address and Phone Number:What actions, if any, were taken in response to the complaint or notice of concern?Who took these actions and when were they taken? (If applicable)What would you like the NAACP to do for you regarding the reported discrimination?Release of LiabilityI affirm that the statements that I have made above are accurate and true to the best of my knowledge and belief. I hereby request the assistance of Culpeper Branch NAACP #7058 in seeking a remedy to the situation described above. I hereby authorize the Legal Redress Committee and elected officers of Culpeper Branch NAACP #7058 to have access to information and documents, which are relevant to my claim of discrimination described above. I understand that once a referral has been made to a volunteer, community agency or private attorney, the Culpeper Branch NAACP will not be responsible for handling this matter. In fact, I further understand that by signing this document, I am agreeing to hold the Culpeper Branch NAACP #7058 and its elected officers harmless for any and all damages arising as a result of my case being mishandled, negligently handled or improperly handled in any way.I confirm that I have read, understand, and agree to the above statement. YesPrint Full Name:Date:Submit Form
