Last Name:
First Name:
Address:
City:
State:
Zip:
Home telephone:
Cell:
Email:

What type of claim do you believe you have? Check all that may apply:

Whistle blower
Failure to pay all wages due or overtime
Failure to provide meal/rest periods
Wrongful termination
Sexual harassment/discrimination
Racial discrimination
Age discrimination
Disability discrimination
Retaliation
Breach of contract

Name of employer:
Approximate number of employees:
Date hired:
Job position:
Compensation:

Per year or per hour

Have you been fired?

Yes No

If so, date of termination:


Are you about to be fired?
Yes No

Briefly explain:


What reason did your employer give you for the termination?


Did you agree with the reason given by the employer?
Yes No

If not, why do you believe your employer terminated you?


If you resigned, date of resignation:

Did you feel forced to resign or did your employer cause you to resign?
Yes No

If so, how?


Did your employer make pre-employment promises about your job that they did not keep?
Yes No

If so, briefly explain:


Do you have a written or verbal employment contract?
Yes No

If so, describe any promises the employer broke?


Do you believe you have been harassed or discriminated against due to any of the following? If so, please select those that apply:

Race
Gender
Age
Physical or Mental Disability
Objecting to wage issues
Objecting to illegal acts
Sexual orientation
Marital status
Requesting or taking a Family Medical Leave

If so, briefly describe the harassment/discrimination?


What is the name and job title of the person who harassed or discriminated against you:

Name:
Job Title:

Did you report the harassment or discrimination to the company?
Yes No

If yes, to whom did you report it (name and job title)?

Name:
Job Tiltle:

What action, if any, did your employer take?


Have you been retaliated against for objecting to any conduct that you believe is illegal?

Yes No
Objecting to illegal practices by your employer
Refusing to do things that you believe are illegal
Objecting to harassment/discrimination
Discussing your compensation or job conditions with others
Other:

Briefly describe the illegal conduct and the retaliation:


Who retaliated against you (identify name and job title)?

Name:
Job Title:

Briefly describe your job duties:


Did you work over 8 hours a day?
Yes No

If so, were you paid time and a half for overtime?
Yes No

Are you an hourly employee?
Yes No

If so, were you paid for all hour that you worked?
Yes No

If so, were you given daily meal and rest periods?
Yes No

Briefly, provide any other additional information you believe we should be aware of:


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