Full Name

Address

Phone Number

Who discriminated against you? Please provide the name and address of the employer - business or organization

Have you ever filed a complaint with any governmental agency?

Yes

Which agency or agencies?

Date filed

Have you filed a grievance with your union?

Name of Local Representative

List the actual date of the most recent date on which the discrimination occurred

Please explain what was done to you

Email any supporting documentation regarding your complaint to

What resolution are you seeking?

Have you retained an attorney regarding this case that we can contact?

Please provide your attorney's name - address and phone number

I affirm that I have read the above charge and that it is true to the best of my knowledge information and belief

I authorize the Virginia Beach NAACP to investigate my complaint

I understand that the NAACP is not a law firm and can't provide me with legal advice or legal representation

I understand that therefore I am not preluded from seeking representation in this matter

Date of Authorization

Name of Complainant