Coatesville NAACP Complaint of Discrimation
Coatesville Area Branch of the NAACP-2257
Complaint of Discrimination
Based on race, color, religion, nation origin sex, age, handicapped status
Please review each question and enter the information requested.
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1. Your Name *
2. Your Phone Number *
3. Your Address
 *
Please include city, state and zip code
4. Your Email Address *
5. Are you an NAACP member?
(Disclaimer: Being a member is NOT required. This question is optional)
Clear selection
6. Explain what unfair thing was done to you? *
7. Was the discrimination because of:  *
(Please check those that apply.)
Required
8. Please select the area in which you are most affected by this
 *
(Please check those that apply.)
Required
9. Who discriminated against you?  *
Name of individual, organization, or other party
10. Address of the party which discriminated against you
Please include city, state, and zip code
11. Were there any other parties involved?
12. Have you filed a complaint with any Governmental agency?  *
13. If Yes, which Gov't agencies? 
14. Have you filed a grievance with your union? *
15. If you have filed a grievance with your union, please provide the name of the union and contact information for your representative.
16. Have you retained an attorney regarding this case? *
17. If you have retained an attorney, provide attorney's name, address, and contact information.
18. Provide the actual date or the most recent date on which this discrimination occurred. *
MM
/
DD
/
YYYY
19. Disclaimer: The purpose of this form is to gather information for the Legal Redress Committee to consider when determining whether the Coatesville Area Branch of the NAACP may be able to assist you with your complaint of discrimination. Completing this form does not constitute an official complaint with a legal authority, such as filing a lawsuit or a complaint with a governmental agency. WE ARE NOT AN ATTORNEY! Nor does completing this form establish an attorney-client relationship between the Coatesville Area Branch of he NAACP and the complainant.                                                    *
20. Your Signature
 *
I affirm that I have reviewed this complaint form and that it is true to the best of my knowledge, information, and belief.

Please sign and date the printed copy of your responses here.
This form must be submitted in print as well
In order to consider your complaint, we have to ask you to print a copy of your responses. The printed copy must be signed and notarized, and submitted to us by mail at the following address:

Coatesville Area Branch of the NAACP
PO Box 668
Coatesville, PA 19320

Please reach out with any questions to:

You can print your responses using your browser's menu, or by hitting CTRL+P. If you're having trouble with this, you can instead print a copy of our traditional paper complaint form, found on chesconaacp.org, and submit that instead. It must also be signed and notarized.

After printing, please click submit.
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