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 is 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