Complaint Of Discrimination Form | Bloomington-Normal NAACP

This is form is for filing a complaint based on race, color, religion, origin, sex, age or handicapped status. Completing this form does not constitute filing an official complaint with a legal authority. At this time, the NAACP is only seeking information to assist you concerning this complaint.

First Name *

Last Name *

Street Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Phone *

Email *

Description Of Complaint *

What was the discrimination because of?

(Please check those that apply)RaceReligionNational OrginSexAgeHandicapped StatusOther

If other, please describe.

Who discriminated against you? *

Address of Discriminator

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Other discriminating parties

Have you ever filed a complaint with any governmental agency(ies)? *

YesNo

Is so, which agency(ies)?

Have you ever filed a grievance with your union? *

YesNo

Name of Local and Representative:

Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Verification