Name * First Name Last Name Email * Phone (Mobile) * (###) ### #### What services are you interested in? * Race Religion Age Disability Sex Veteran Status Gender How were you mistreated or discriminated against? * By whom were you mistreated, harassed, or discriminated against? * 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 NAACP Columbus, GA Branch in seeking a remedy to the situation described above. I hereby authorize the officers of the NAACP Columbus, GA Branch to have access to information and documents, which 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 NAACP Columbus, GA Branch WILL NOT BE RESPONSIBLE for handling this matter. In fact, I further understand that by submitting this document, I am agreeing to HOLD the NAACP Columbus, GA Branch harmless for any and all damages arising as a result of my case being mishandled, negligently handled, or improperly handled in any way. 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 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. COMPLETION OF THIS FORM Completing this form does not constitute filing an official complaint with legal authority. At this time the NAACP Columbus, GA Branch is only seeking information to assist you concerning this complaint. Please send this information and copies of sustaining documents in an envelope marked confidential to NAACP Columbus, GA Branch – 233 12th Street Suite 515 – Columbus, GA 31901Text Thank you!
