NAACP Member  
  Name  
  Address  
  City        
  State  
  Zip  
  Home Phone  
  Work Phone  
  Cell Phone  
  Home Email  
  Contact Method  
   
  Please note the following definitions:
 
  • African American/Black - People having origins in any of the Black racial groups of Africa. Not of Hispanic origin.
  • Native American, America Indian or Alaskan Native - Persons having origins in any of the original peoples of North America and who maintain cultural identification through tribal affiliation of community recognition.
  • Hispanic - Persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture of origin, regardless of race.
  • Asian or Pacific Islander - Persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, of the Pacific Islands. This Area includes, for example, China, India, Japan, Korea, the Philippine Islands or Samoa.
  • White - Persons having origins in any of the original peoples of Europe, North Africa or the Middle East. Not of Hispanic origin.
 
  Race
 
  Sex
 
  Date of Birth
 

Do you have a complaint regarding the following?
    Employment Discrimination
    Race
    Sex (gender/female discrimination)
    Sexual Orientation
    National Origin (ethnicity discrimination)
    Age
    Religion
    Education
    Medical
    Disability
    Veteran's Status
    Retaliation
    Whistleblowing (employees who blow the whistle regarding fraud or misconduct)
    Wage and Hour (failure to pay full amount of compensation owed)

    Consumer Fraud (deceptive and fraudulent practices such as late/hidden fees)
    Leasing: auto or equipment (excessive fees, late fees, hidden fees)
    Credit card issues (excessive fees, late fees, hidden fees)
    Mortgage issues (excessive fees, late fees, hidden fees)
    Insurance issues (excessive fees, late fees, hidden fees)
    Predatory lending (discrimination against minorities in lending)
    Deceptive billing practices (e.g. cell and telephone charges)
    False and misleading advertising
    Defective products

    Public Accommodations Discrimination
    Denial or improper treatment (restaurants, hotels, stores, hair cutting, etc.)
    Racial profiling
    Housing discrimination

    Criminal Law
    Racial profiling
    Unlawful arrest (battery, unreasonable use of force)

  Other

 
 
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