Contact Firm

Full Name (first & last) (required)

Phone Number (required)

Email Address (required)

What is the name of your employer? (required)

In what state did you physically work for the employer? (required)

What was your job title?

Approximately, how long did you work for this employer? (Ex: 4yrs & 2mos)

How were were you paid? (required)
SalaryHourlyCommissionOther
How much were you paid on an annual basis? (required)

What was your employment classification?
EmployeeIndependent ContractorUnknown
What was your work schedule like?
Full-timePart-timePer diemSeasonalOther
What is your employment status now? (required)
TerminatedLaid OffResignedStill EmployedUnknownVoluntary Leave of AbsenceInvoluntary Leave of AbsenceOther
If you answered "Terminated," "Laid Off" or "Resigned," what date did this happen?

What kind of adverse actions do you believe were taken against you?
HarassmentDiscriminationWrongful TerminationRetaliationFailure to HireFailure to AccommodateFailure to PromoteFailure to Prevent Harassment/DiscriminationA Combination of Some of the AboveOther
When was the last time one of these adverse actions was taken against you? (date)

Did you ever make a complaint (verbally or writing) about any of these adverse actions?

If yes, when did you make the complaint?

If yes, who did you make the complaint to?

Briefly, tell us the basics of your case:

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