Employment Questionnaire If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Date * Name First Name * Last Name * Address Address Line 1 * Address Line 2 City * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State * Zip * Email * Home Phone Cell Phone Work Phone Do you have a Facebook account? * YesNo If so, what is your name on Facebook? Do you have a Twitter account? * YesNo If so, what is your Twitter handle? Do you have an Instagram account? * YesNo If so, what is your Instagram username? How did you find us? Employer with whom you have legal issue? Include address where you worked for employer. * How many employees work for the employer? * Length of time employed * What was your salary and total yearly compensation and benefits? * Did you work overtime? If so, were you paid for overtime hours and how were you paid? Please include the total number of hours worked per week. * Specific date of hire * Have you been * Terminated?Demoted?Denied Promotion?Denied Raise?Refused job applied for? What was the date on which you were adversely affected by your employer? * What was the stated reason for the adverse action? Was it written or oral? * What is the name and position of the person who notified you of the adverse decision? * Who do you really think made the decision - the person who really wanted you terminated? * What do you think is the biggest reason for that person's decision to terminate/demote you? * Have you signed an arbitration agreement with the employer? * Have you been offered another job? If so, please describe the job and compensation. * What is your date of birth and current age? * What was your job title or what was the job you were seeking? * In case of termination, how much, if any, severance pay were you given? Have you signed a severance agreement or release?If you have signed an agreement with the employer, please email a copy to our office. * What is the age, race and gender of your replacement? Have you found other employment? * YesNo, but expect to soonNo, and do not expect to soon If you have found other employment, please give your new salary and benefits. Did you take or keep any company documents or any company property from the job in question? If so, please explain. * Do you believe your case may involve any of the following? * Age discriminationSex/gender discriminationRace or national origin discriminationSexual harassmentPregnancy discriminationDisability discriminationReligious discriminationLibel or slanderBreach of contractFired related to a serious medical condition to your or a family memberAnother company got you fired Please specify if other Describe in detail why you believe that you were discriminated against? * Please explain in detail the events leading up to your termination or discrimination. * At the job in question, did you fill out a written job application or submit a resume? If yes, does it contain any misstatements, omissions or inaccuracies as to your education, qualifications, criminal record, work history, etc.? If so, please explain. Please describe in detail any negative in your personnel file including rule violations, written warnings or reprimands, etc. Briefly describe your main complaint. * What do you want to accomplish through an attorney? * Are you currently thinking of filing for bankruptcy? * YesNo If so, please name any attorney(s) you have talked to about filing for bankruptcy. Date, if any, of any charge filed with the Equal Employment Opportunity Commission or Texas Workforce Commission? Please give a summary of your work history over the last 10 years. Include the name of the employer, dates of employment, reason for leaving and pay. * Are you aware of any kind of deadline with respect to your need for legal advise or representation? If so, please explain. Please give a summary of any prior injuries you have had over the last 5 years. Please give a summary of any criminal charges you have had in the last 10 years. * We support your right to earn a living. Contact us to learn how we can make employment law work in your favor.