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 Georgia NAACP in seeking a remedy to the situation described above. I hereby authorize the officers of the Georgia NAACP 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 GEORGIA NAACP WILL NOT BE RESPONSIBLE for handling this matter. In fact, I further understand that by submitting this document, I am agreeing to HOLD the GEORGIA NAACP 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 a legal authority. At this time the State Of Georgia NAACP 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: State of Georgia NAACP 2001 Martin Luther King Jr. Drive, Suite 307, Atlanta, Georgia 30310