Name (required)
Email (required)
Phone (required)
Current or Former Employer
Job Title
Annual Compensation
Were you fired? YesNo
When were you fired?
What reason were you given for termination?
If you think the reason for termination is wrong, what do you feel is the real reason for termination?
Did you resign? YesNo
When did you resign?
Why did you resign?
Have you been retaliated against for (select one) Blowing the whistle of illegal conduct?Refusing to engage in illegal conduct?Complaining about discrimination and/or harassment?Engaging in protected activity (taking family or medical leave, taking time off to vote or serve on jury duty, etc...)?
Please briefly describe the retaliation.
Who retaliated against you?
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.