CONTACT INFORMATION Name Address Phone Number Email Best Time To Call You EEO INFORMATION Gender: MaleFemale Date of Birth: Race/Color: National Origin: Religion: Pregnant? YesNo Disabled? YesNo If yes, what is the disability? Veteran? YesNo If yes, what branch and dates? EMPLOYER INFORMATION Employer Status: Current EmployerFormer Employer Company name of your current/former employer: Job Title: Start Date: End Date: Number of Employees: How Were You Paid? HourlySalaryCommission Amount $: TERMINATION Were You Terminated? YesNo Reason given: AREAS OF CONCERN Select all that apply Wrongful TerminationDiscriminationUnpaid Wages/OvertimeMedical Leave/DisabilitySexual Harassment/Hostile Work EnvironmentRetaliation/Whistleblower ProtectionEmployment AgreementsNon-Compete AgreementsSeverance AgreementsWorkplace ViolenceHealth and Safety RegulationsCivil RightsBusiness LitigationOther DESCRIPTION OF CLAIM Describe each act taken against you that you believe violates your legal rights, including the dates: DISCRIMINATION/HARASSMENT On what basis do you believe you were discriminated against or harassed (if applicable)? GenderAgeRace/ColorNational OriginReligionPregnancyDisabilityVeteran Status Were there any derogatory comments, jokes, slurs, graffiti or other communications directed toward you that referenced your membership in one of the above-listed EEO categories? YesNo If yes, describe each communication, including the employee that made it and the dates: Are there other employees who were treated better than you in the same situation (e.g., disciplined less severely for the same violation)? YesNo If yes, explain: COMPLAINTS MADE Did you complain to management about the actions taken against you? YesNo If yes, provide the details, including a description of what you said and the dates: ACTIONS TAKEN Have you filed a lawsuit, EEOC charge, grievance, administrative appeal, arbitration demand, or taken any other action to resolve the matter in question? YesNo If yes, describe the nature of the lawsuit or other action and the date filed: OTHER ATTORNEYS Have you worked with other attorneys in connection with this matter: YesNo If yes, provide the name, address and telephone number for each attorney and explain why you are no longer working with him/her: UNEMPLOYMENT Have you applied for unemployment insurance benefits? YesNo Outcome: ApprovedNot Approved OTHER LAWSUITS/LEGAL ACTION Have you ever been a party to any other lawsuit or other legal action (including EEOC charges, administrative agency appeals, bankruptcies, divorces, collection actions, landlord/tenant matters, personal injury claims and small claims court matters)? YesNo If yes, describe the nature of the lawsuit or legal action, the date filed and the name of your attorney. ABILITY TO PAY If required, are you able to pay an initial upfront retainer (typically, at least $2,500)? YesNo REFERRAL SOURCE How did you learn of our firm? If applicable, which of the firm’s attorneys were you referred to? Please leave this field empty.