Public Safety & Criminal Justice

National Association for the Advancement of Colored People
NAACP Michigan City Branch #3061
P.O. Box 755
Michigan City, Indiana 46361
(219) 229-3524 (phone)
Email: naacpunit3061@gmail.com

Are you a current member of the NAACP?

Yes

Your Information Section

Your Name

First Last

Your Email Address

Enter Email Confirm Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone

Work Phone

PLEASE NOTE THAT WE W ILL NOT PROCESS YOUR APPLICATION UNLESS ALL QUESTIONS ARE COMPLETED (ON BOTH PAGES), ALONG WITH A ONE-PART SUMMARY OF THE ALLEGED DISCRIMINATION THAT OCCURRED. INCOMPLETE APPLICATIONS WILL NOT BE INVESTIGATED.

Legal Status Section

Do you currently have an attorney?

Yes

Attorney's Name

Attorney's Address

City, State, Zip

Attorney's Telephone

Attorney's Fax Number

Has a lawsuit been filed?

Yes

Please submit a copy of lawsuit documents

Drop files here or

Max. file size: 250 MB.

Have you filed a complaint with the EEOC?

Yes

Date Filed with EEOC

Have you filed a complaint with Fair Employment & Housing?

Yes

Date filed with Fair Employment & Housing

Please List Agency in which you are filing complaint against:

School District

Business Government Agency

Law Enforcement

Other

List Other Agency

Discrimination Section

Type of Discrimination

List Other Discrimination

How were you discriminated against?

By whom were you discriminated? Include name(s), race, and gender of each

Name

Race

Gender

Where did the discrimination take place? Cite location/address for each incident:

Address

City

State

Postal Code

Did anyone witness the discrimination that took place?

Yes

Witness (s)

Name

Address

Phone

To date, what actions have you taken so far?

What was the affect or impact of the discrimination behavior on you?

To date, what actions have you taken so far?

Have you filed a complaint with or notified any other organization o r and individual regarding this matter?

Yes

Provide Name, Address, and Phone #

Name

Address

Phone #

What actions, if any, were taken in response to the complaint or notice of concern?

Who took these actions?

When were these actions taken?

What would you like the NAACP to do for you regarding the discrimination?

RELEASE OF LIABILITY

I 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 the La Porte County Branch of the NAACP in seeking a remedy to the situation described above. I hereby authorize the officers of the La Porte County NAACP Branch 3061 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 La Porte County NAACP Branch 3061 WILL NOT BE RESPONSIBLE for handling this matter. In fact, I further understand that by signing this document, I am agreeing to HOLD the La Porte County NAACP Branch 3061 harmless for any and all damages arising as a result of my case being mishandled, negligently handled or improperly handled in any way.

Full Name(Required)

First Last

Date

Signature(Required)

Section 704 (a) of the Civil Rights Act of 1964, (as amended), Section 4 (d) of the Age Discrimination in Employment Act of 1967, (as amended), and various other civil rights laws make it an unlawful employment practice for an employer; employment agency; or labor organization: to discriminate against employees, applicants for employment, member or applicant for membership, because the employee, member or applicant has opposed an unlawful employment practice, made a charge, testified, assisted, or participated in any manner in an investigation, proceeding or hearing.

Completing this form does NOT constitute filing an official complaint with a legal authority. At this time the NAACP Michigan City Branch 3061 is ONLY seeking information to assist you concerning this complaint. Please mail this information and copies of sustaining documents in an envelope marked "CONFIDENTIAL" to: NAACP Michigan City Branch 3061 P.O. Box 755 Michigan City, IN 46361.