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*Email Address:
Mailing Address:
Home Phone:
Business Phone:

Ok to Call? YesNo
How were you referred to us?
 Reason for contacting us at this time:
Discrimination: Nature of Discrimination:
Failure to Hire (Date turned down for employment: )
Denial of Promotion (Date promotion given to another:
Pay Discrimination (Date pay differential started:
Termination (Date of Termination:

Who got position in question?

Describe that person (how different from you):

Who discriminated against you?

His/Her Title:

What reason was given for the decision?
Harassment: Describe (incl. when):
Other form of discrimination: Describe:
Basis of Discrimination/Harassment:
Age (Date of Birth:
Disability (Condition:
Marital Status
National Origin (Describe:
Race (Describe:
Sexual Orientation
Breach of Contract (Be prepared to provide copy) (Describe: )
Review severance agreement (When Given: ) (Deadline: ) (Be prepared to provide copy)
Covenant Not to Compete or other Post Employment Issues (Be prepared to provide copy)

Defamation: What was said about you, by whom, and how is it false?

Employer contacting us about:
                               No. of Employees:  
Your Title:   Pay Rate:   per 
Date of Hire:   Union Member: YesNo  (If Yes, name of union  )
Date of Termination (if no longer working there:
 If you were terminatied, are you getting unemployment benifits ?  Yes   No
 (If no, did you apply ?  Yes  No
Do you have an Individual Employment Contract: (Be prepared to provide copy)  YesNo
Is there a Handbook: (Be prepared to provide copy)  YesNo
Is there a Harassment Policy: (Be prepared to provide copy)  YesNo

Current employer (if different from above): Employer:

Your Title:   Pay Rate:   per  Date of Hire: 

Employer before the one at issue: Employer:

Your Title:   Pay Rate:   per   Date of Termination: 
Prior litigation experience (if any):
Ever terminated/force to resign employment?


 Did you complain about the conduct at issue?YesNo If so, when:
  If so:  VerballyWritten (if written, Be prepared to provide copy)
  If so: To whom:  Title:
  What happened to complaint:
 Have you filed any formal complaints regarding this issue? YesNo (If so, be prepared to provide copy)
If so, with whom:
 EEOC  NYS Division of Human Rights
 NLRB  Dept. of Labor
 Other, Describe: 
If so, when did you file your complaint :
If so, current status:
 Case dismissed ?  Yes No
 If so, date received:
Right To Sue letter received? YesNo (Be prepared to provide copy)
If so, date received:

For disabled employees:

Does the employer know about your disability? YesNo
Does the employer consider you to be disabled, even if you are not? YesNo
When did the employer become aware of the condition?
Accommodation requested: YesNo What was requested:
How have you been financially damaged (if at all): Explanation for amount:
In what non-monetary ways have you been damaged (if any):
Medical treatment (if any):

Witnesses (describe knowledge and provide contact information):
Other Evidence (Be prepared to provide copies of any other documentation)
Any additional information/background:
Have other attorneys worked on this matter?
If so,  Who?
Special concerns:

The information you obtain at this site is not, nor is it intended to be, legal advice. You should consult an attorney for individual advice regarding your own situation.

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