Please complete the form below by entering your information. Fields marked with an * are required for the form to work.
*Name:
Address:
City:
State:
Zip:
Phone:
*E-mail:
Were you fired? Select Yes No
If fired when?
If not, do you think you are about to be fired? Select Yes No
When?
Were you given a reason for being fired/about to be fired? What reason?
Do you think it's really for a different reason? If so what reason?
Did you quit? Select Yes No
When did you quit?
Why did you quit?
Were you or are you being harassed? Select Yes No
When was the last time?
What (briefly) constituted the harassment?
Why do you think you were being harassed? (race, age, gender, other - please name)
Did you report the discrimination or harassment to anyone in your company? Select Yes No
Who did you report it to?
What is their position?
Are they still employed there? Select Yes No
Did anyone witness the discrimination or harassment? Select Yes No
Who witnessed it?
What did they see or hear?
Did you report the discrimination or harassment to any government agency? Select Yes No
Which agency?
When was it reported?
Did you file a written complaint? Select Yes No
Did you receive anything in writing notifying you that you can file a lawsuit? Select Yes No
When did you receive it?
Are you presently employed? Select Yes No
Where are you presently employed?
How long have you been employed?
What do you earn?
If you were fired or quit, how long were you there?
How much were you making?
Please indicate any other facts that you believe are important. We need to know what your employer did to you, what reason you think they did it which you believe it illegal, and what damage or loss you suffered because of what they did?
