Contact

1. Name
2. Phone
3. E-mail
4. Address

1. Employer Name
2. Address
3. Position
4. Salary
5. Date of Hire
6. Number of employees
7. Employer name on paycheck (if different than above)

1. Are you an exempt employee?

   YesNo

2. Are you paid overtime?

   YesNo

3. Are you required to attend any time of arbitration to resolve any disputes with this employer?

   YesNo

1. Average numbers of hours worked per week
2. If these hours are reported how are they done (Time clock, handwritten, computerized)?

1. Do you receive any type of bonus?

   YesNo

1. Were you ever required to be at work, but not get paid for the time you were there? (For example, required to show up early or stay late)
2. Date of termination (if applicable)
3. Reason given for termination
4. Reason YOU believe you were terminated

Please check each characteristic below you believe is the basis for the action taken against you

1. Race / Color
   
2. National origin
   
3. Age
   
4. Gender
   
5. Pregnancy
   
6. Religion
   
7. Disability or perceived disability
   
8. Sexually harassed
   
9. Sexually charted comments
   
10. Sexual favors in exchange for work related benefits
    
11. You complained about discrimination against yourself
    
12. You complained of discrimination against others
    

1. Did you ever report the discriminatory incidents to anyone? Is so, to whom?

1. Have you filed a complaint with the EEOC and/or the MCHR?

   YesNo

1. If yes, when
2. Have you received a Notice of Rights to Sue from the EEOC and/or the MCHR?
3. If yes, what is the date on the letter

1. Have you ever sued a former employer before?
2. Have you found another job?
3. How did you hear of us?

The use of the Internet or this form for communication with the firm or any individual member of the firm does not establish an attorney-client relationship. Confidential or time-sensitive information should not be sent through this form.

1. I have read and understand the disclaimer.