CONTACT INFORMATION

Name

Address

Phone Number

Email

Best Time To Call You

EEO INFORMATION

Gender:

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 Litigation
Other

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.