First Name    M.I.    Last Name   

Address    City    State    Zip   

Home Phone (Including area code No dashes,dots,or spaces)    Work/Cell Phone Number    E-mail   

How did you find out about us? Internet Search Friend Martindale Hubbell Attorney Referal Other    Please provide name of referral Attorney   

Name of the employer that has wronged you   

Employer Address    City    State    Zip   

Phone    Dates of employment From (YYYY-MM-DD)    To   

Your Position/Title    Value of Salary & Benefits    Total number of employees there   

Please indicate if you have experienced any of the following Termination Demoted Denied a Promotion Refused a Job Other    Date you were notified    Effective Date   

Did you receive any Severance Pay Yes No   

Please provide an explanation
  

What position were you seeking   

What reason did the employer give for the action, if any

Name and Title of the person who informed you of the Company's decision    Did you sign a release or waiver? Yes No   

Do you believe your case my involve any of the following Age Discrimination Sex Harassment Sex Discrimination Race Discrimination Disability Discrimination Whistle-Blower Activity   

Briefly explain your concern.

Briefly describe your problem

Were you denied medical or sick leave Yes No

If so, describe the reason for your requested leave

When did request the leave(date)   

Additional Employment Options

Have you found other employment Yes No     If yes, what is your current employer's name   

Employer Address    City    State    Zip   

Phone    Current Position    Current Salary   

If No, please explain why and describe your efforts to find employment

Other Legal Claims

 Is the reason for you legal claims involve any of the following matters Libel Slander Breach of contract Fired for refusing to perform or for reporting an illegal act Fired for exercising rights under worker's compensation law Failure to pay wages commission bonuses or other monies   

If so, what do you wish to accomplish through an Attorney

Have you filed a complaint/charge with the Equal Employment Opportunity Commission (EEOC) Yes No    Exact date the complaint/charge was filed   

Have you received a decision or Notice of Right to Sue from EEOC Yes No    If yes, what date did you receive the notice   

Have you ever filed a complaint against another employer Yes No

If yes, Employer Name    Employer Address    Date   

Have you ever been involved in a lawsuit before, including workers compensation claims and personal injury actions Yes No

If yes, Employer Name    Employer Address    Date