DO I HAVE AN EMPLOYMENT CASE?

Name


Street Address


City


State   Zip

Home Telephone 


Cellular Telephone


E-mail

Name of your current or former employer:


Your job title:


Your annual compensation:

Have you been fired?
Yes No

If fired, when?

If not fired, do you think you are about to be fired?
Yes No

When?

Were you given a reason for your termination/why you are about to be fired?
Yes No

If so, what is the reason given by the employer?

Do you think the reason is true?
Yes No

If not, what is the real reason?

Did you resign?

Yes No

If yes, when?

If yes, why?

Have you been harassed or discriminated against because of your membership in a protected class (race, religion, creed, color, national origin, ancestory, physical disability, mental disability, medical condition, marital status, gender, gender identity, age, or sexual orientation)?
Yes No

If yes, please briefly describe the harassment/discrimination?

Who harassed/discriminated against you (identify name and job title)?

When was the last time that you were harassed/discriminated against?

Did you report it to the company?
Yes No

If yes, to whom did you report it (identify and job title):

Did anyone witness the harassment/discrimination?
Yes No

If yes, who and what do you believe they witnessed:

Have you been retaliated against for (check one)

blowing the whistle on illegal conduct?

refusing to engage in illegal conduct?

complaining about discrimination/harassment?

engaging in protected activity (taking family or medical leave, taking time
off to vote or serve on jury duty, etc...)?

If yes, please briefly describe the retaliation?

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

Please indicate any other facts that you believe are important.  We need to know what your employer did to you, why they will say they did it to you, why you believe it is illegal, and what damage or loss you suffered because of what they did.

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DO I HAVE A PERSONAL INJURY CASE? (back to top)

Name


Street Address


City


State  Zip

Home Telephone 


Cellular Telephone


E-mail

Please enter a brief description of the facts surrounding your personal injury claim (e.g., how you were injured, witnesses, your damages):

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DO I HAVE ANOTHER TYPE OF CASE? (back to top)

Name


Street Address


City


State  Zip

Home Telephone 


Cellular Telephone


E-mail

Please enter a brief description of the facts surrounding your personal injury claim (e.g., how you were injured, witnesses, your damages):

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