By filling out this form, you are helping the American Civil Liberties Union of North Carolina gather valuable information regarding the uses and patterns of racial profiling by police at the state, county and local levels.  Racial profiling can occur in different contexts to racial, ethnic and religious minorities.  All of the information you provide will be kept STRICTLY CONFIDENTIAL.  If you have questions about this form, please contact us at 919-834-3466.

We CANNOT promise that the information you provide will lead to specific action by the ACLU of North Carolina.  However, the information you provide will help us support local laws that protect individuals from racial discrimination and/or identify jurisdictions where we could present cases of racial discrimination in court.  You may receive a request from the ACLU of North Carolina to use your information for: 1) legislative testimony, 2) litigation, or 3) telling your story to the media.  We will NOT do this without your prior authorization.  Thank you for cooperating with the ACLU of North Carolina.

Personal Information
Information About the Racial Discrimination Incident
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