Legal Redress – Rockbridge NAACP

If you want the NAACP to investigate a complaint of discrimination, please fill out the form below. You can then speak to a member of the Executive Committee of the local chapter, and a determination will be made as to whether the NAACP can assist you in pursuing your complaint.

Date *

Name *

Email *

Phone Number *

Mailing Address *

Place of Employment *

Employer Address *

Describe the incident: *

Describe what specifically what happened that caused you to file this complaint.

If "Other," please describe

Please describe the circumstances in which you were discriminated against, or were the victim of an unlawful act: *

By whom were you discriminated against? - Please include name, race and gender of each individual: *

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

Were there witnesses to what took place? Please include name and as much contact information as possible (address, email, phone) for each individual: *

What was the effect or impact of the discriminating behavior 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?

Name of person(s) or organization(s) with whom you have filed your complaint:

What actions, if any, were taken in response to your 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 this matter? *

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 Rockbridge County, Virginia Branch of the NAACP in seeking a remedy to the situation described above. I hereby authorize the officers of the Rockbridge County NAACP to have access to any information and documents, hard copy or electronic, that are relevant to my claim of discrimination described above. I understand that once a referral to a volunteer, community agency or private attorney has been made, the Rockbridge County NAACP will not be responsible for handling this matter. By checking the box below, I agree to hold the Rockbridge NAACP harmless for any and all damages arising as a result of my case being mishandled or any negligence in any way. *

I agree

This box must be checked before the claim can be investigated.

Full Legal Name *

Non-Retaliation Requirements: 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 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. Completion of this form does not constitute filing an official complaint with a legal authority. At this time the Rockbridge County NAACP is only seeking information to assist you concerning this complaint.