About the firm Practice Areas Our Attorneys Do I have an employment claim? Contact

Employment Claim Form

Please provide us with the following information via email.  Upon receipt an attorney from our office will contact you to discuss your case.

Name:
Address:
Email Address :
Telephone:
Date of Birth:
Salary:
Job Title:
Employer/Company with which you have a legal problem:
Dates of employment with this company:
Have you been (and date):
Terminated
Demoted
Denied promotion
Refused a job you applied for
Other
  Please explain:
What was the stated reason:
Name of person notifying you:
This person's position:
Who do you think really made the decision:
What do you think it the real reason for that person’s action:
In case of termination, were you offered severance, if so, how much:
Have you signed a release or waiver:
Yes No
Do you believe your case may involve the following:
Age discrimination
Sex discrimination
Sexual harassment
Disability discrimination
If so, what is your disability:
Did the company know about your disability:
Yes No
Race discrimination
Libel or slander
Breach of contract
Discharge for refusing to perform or complaining about an illegal act
Discharge for filing Workers' Compensation claim
Other
  Please explain:
Briefly describe your main complaint:
What do you want to accomplish through an attorney?
Have you filed a claim with the EEOC or a state agency?  If so list the date:
Yes
No  
Are you aware of any kind of deadline with respect to your need for legal advice or representation?  If so, please explain:
Yes
No  
 

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