Name

Address

City

State / Province

Zip / Postal Code

Cell Phone

Email

Date Of Birth

__________________________________________________________________________________

Referred By

Were you referred to a particular attorney in our office?
Yes   If So Who?

Have you spoken with any other attorneys?
Yes   If So Who?

Date Of Adverse Action

___________________________________________________________________________________

Name Of Employer

Type Of Business

How Long Employed

Position

___________________________________________________________________________________

Please check any of the areas you feel apply to your case:

Discrimination:
Race
Age
Disability
Gender
Religion
Other Discrimination
If Other Please Describe

Wages:
Overtime
Tips
Retaliation
Other Wages
If Other Please Describe

Other
Defamination
Whistleblower

___________________________________________________________________________________

Main Area Of Work Affected Hiring Harassment Promotion Wages Firing Training

Describe what happened to you. Including the actions taken against you or others, that you consider important, with relavant dates, and persons involved