Employment Law, Employee Contact Form

*First Name

*Last Name

*Email Address

*Phone Number

*Zip

Street Address

Apt/Ste

Incident Street Address

Incident Apt/Ste

*Incident Zip

Business Phone

Cellular or Pager

Are you representing yourself or your business?
Self  Business 

If you are representing a business, what is the business name?

Business address, including county.

What type of business is it? (sole proprietorship, LLC, etc.)

Have you used any other personal or business name(s) in the last six years? If yes, please list here:

If you are representing a business, please state your relationship to the business? (owner, manager, supervisor)

Does the nature of your claim relate to wrongful termination?
Yes  No 

If yes, please describe:

Does the claim involve discrimination?
Yes  No 

If yes, please describe the discriminatory treatment:

If the discrimination relates to age, please provide your age:

Are you over 40 years of age?
Yes  No 

Please list any disabilities which employer was aware that you suffer from:

If the discrimination relates to race or national origin, please list race or national origin:

If the claim relates to allegations of invasion of privacy, please discuss the circumstances surrounding the allegations?

If the claim involves disparate wage treatment, please give:

Wages paid for the period involved:

Wages claimed:

Wage paid to others performing same or similar tasks with similar training or experience:

Does your claim relate a violation of your collective bargaining rights?
Yes  No 

Are you a union member?
Yes  No 

If yes, please provide:

Name of union:

Member identification number:

Name of union representative:

Contact number for union representative:

Special concerns:

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