UNIVERSAL Investigation/ ASSESSMENT/Complaint FORM
NB: We at CLRC suggest that this form should be:
- Edited to custom fit your organizational name and logo.
- Copied to a word file (Microsoft Word, Page etc) for proper formatting and a better read and printed form.
FIX this FORM to FIT your ORGANIZATION.
www.CivilAndLaborRightsConsultants.com
Box 150001
Arlington TX 76015
(817) 467-3087
Request for ASSESSMENT
(Investigation/Complaint)
FORM CLRC-I1
Case Number (Numero del Caso): # ___________________________
Today's Date (Fecha De Hoy): ____________________
Name/s of Complainant/s (Nombre/s de la/s Victima/s):___________________________________________
Full Home Address (Domicilio Completo): _____________________________________________________
Work Phone (Teléfono de trabajo):__________________ E-Mail (Domicilio Internet): ________________
Phones Personal (Teléfonos personales): ____________________ FAX (Teléfono Fax ):______________________City and County/Parish of incident: _________________________ _________________________
(Ciudad y Condado Del Incidente)
WHO IS YOUR COMPLAINT being FILED AGAINST.
CONTRA QUIEN HACE UD. ESTA QUEJA.
Name/Title of Accused (Nombre/Titulo Del Acusado): _____________________________
Phones (Teléfonos): _________________________ _________________________Full Address (Domicilio Completo):
___________________________________________________________________________________
Fax phone (Teléfono Fax): ______________________ E-Mail (Domicilio Internet): ____________________
Brief narrative description of incident which the complaining party feels as a violation of his/her Civil Rights.
(Breve narración del incidente el cual UD. siente violo sus Derechos Civiles)
PLEASE you MUST put your complaint here in a few words.
(POR FAVOR TIENE que ponder su queja aqui en pocas palabras.)
Date of incident (Dia del incidente): __________________
Mail us additional pages if necessary (Envie por correa más paginas si es necesario.)
I attest that this report of a case where it is my belief that my Civil Rights were violated is done with express purpose of giving CLRC permission to investigate my grievance/complaint and that I am not represented by legal council at present. Once I am Represented by a lawyer, I shall notify the CLRC personnel assisting me with this issue. I permit CLRC to work with any Union or other civil rights entity. I am solely responsible for my actions and have not given power of attorney to another agent in this matter.
(Afirmo que al reporter este caso, es mi certitude que mis Derechos Civiles fueron violados y lo hago con el propósito de dar permiso a CLRC de investigar mi queja y que no estoy representado por abogado/a. Si yo obtengo un abogado le dare saberlo a los representantes de CLRC cuales me están ayudando con este caso. También permito que CLRC compare este caso con cualquier otro grupo de drechos civiles o cindicato. Yo soy responsible de mis aciones y no le he dado poder de abogado sobre este asunto a nadie.)
Signature of complainant or injured party.
(Firma en molde Del acusador o dañado.): ______________________________________
Print Name of complainant or injured party.
(Nombre en molde Del acusador o dañado.): ______________________________________
Witness or Notary (Testigo o notario) : _________________________________ Signature (Firma)
Please print name: __________________________________ (Nombre en molde)
* SEAL (Cello) *
This signed document once sent to, received and accepted by CLRC-Civil Rights person with CLRC is a legal document and may be used as evidence.
(Este docmento firmdo, entregado y aceptado por un(a) p[ersona de Decechos Civiles de CLRC se considerara un documento legal y se puede usar como evidencia..)