Name
Pronouns
Phone
Email
Mailing Address
Best method to contact (email or phone)
How Did You Find Our Firm?
Were you referred to anyone in particular, or the firm as a whole?
Name of the subject employer? If this is not an employment claim, identify the adverse party.
Employer website
Where did you work for the employer? If you worked from home, please say so.
Where is the employer headquartered?
No. of Employees
What is your title/position, or, if this is your former employer, what was your most recent title/position?
How much were you paid? Include all forms of compensation (e.g., salary, bonus, equity, etc.)
How long have you worked/did you work for the subject employer? If you no longer work there, when did your employment end?
What “adverse action” has your employer taken against you, if any? In other words, what action did they take that harmed you?
When did that action happen?
On what basis do you think your employer’s action was wrongful? For instance, was it retaliation for reporting some illegal activity? Did they act in a discriminatory manner, and if so, on the basis of what protected characteristic did they discriminate? Or are you unsure of why the action was wrongful?
What is your current employment status? For instance, perhaps you: (a) remain employed by the subject employer; (b) have obtained new work (if so, please note how long you were out of work and your current compensation); or (c) remain unemployed.
Names of supervisor(s) and/or discriminating official(s)
SUBMIT
