Step 1 of 4 25% Name* First Last Phone*Email* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How were you referred to us?* Reason for contacting us at this time:* Discrimination Breach of Contract Severance Agreement Issues Restrictive Covenant Defamation Whistleblower Other Nature of Discrimination* Age Disability Gender/Pregnancy Marital Status National Origin Race Religion Sexual Orientation Retaliation Other Date of Birth* MM slash DD slash YYYY What is the nature of your disability?*Does the employer know about your disability?* Yes No When and how did the employer become aware of the condition?*Does the employer consider you to be disabled, even if you are not?* Yes No Did you make a request for accommodation?* Yes No What was requested and what happened in response to your request?*What is your marital status?* What is your national origin?* What is your race?* What is your religion?* What is your sexual orientation?* Did you complain about the conduct at issue?* Yes No Date(s) you complained* How did you complain?* Verbally In writing To whom did you complain?*Name and title What happened after you complained?*How were you subjected to discrimination?* Harassment / Hostile Work Environment Failure to Hire Denial of Promotion Pay Discrimination Termination Other What was your termination date?* MM slash DD slash YYYY When were you denied the position?* MM slash DD slash YYYY Please describe the issue in as much detail as possible.*Date of Contract* MM slash DD slash YYYY Date of Contract Breach* MM slash DD slash YYYY Please describe the nature of the contract breach.*Date You Received Severance Agreement* MM slash DD slash YYYY Upload Severance Agreement (if you can).Max. file size: 256 MB.Please describe the nature of the restrictive covenant and how it is allegedly being violated.*Please upload the restrictive covenante contract (if you can).Max. file size: 256 MB.When was the incident?* MM slash DD slash YYYY What was said about you?*Who was it said by?* What was said about you?*How is the satement false?*When did you raise a concern about the issue and to whom?*Have you filed any formal complaints regarding this issue?* Yes No With whom was the complaint filed?* EEOC NYS Division of Human Rights MSPB NLRB NYS Dept. of Labor U.S. Dept. of Labor Other Name of agency* Date of Complaint(s)*Is the complaint still open?* Yes No What is the current status of the complaint?*Date closed* MM slash DD slash YYYY Employment InformationWhat is the name of employer you are contacting us about?* Number of employees?* Your title* Your pay rate*amount/time period Date of Hire* MM slash DD slash YYYY Union Member?* Yes No Name of Union?* Are you still employed there?* Yes No Are you receiving unemployment benefits?* Yes No Date of Termination* MM slash DD slash YYYY Did you apply for unemployment benefits?* Yes No Do you have an Individual Employment Contract*(Be prepared to provide copy) Yes No Is there an employee handbook?*(Be prepared to provide copy) Yes No Is there a Harassment Policy?*(Be prepared to provide copy) Yes No Previous Employer informationWho was your employer before the one at issue?* Previous Employer Date of Hire* MM slash DD slash YYYY Previous Employer Last Date of Employment* MM slash DD slash YYYY Title at Previous Employer Previous Employer Pay Rate amount/time periodNew Employment InformationDo you have new employment?* Yes No New Employer informationNew Employer Name* Your title* Pay rate*amount/time period Date of hire* MM slash DD slash YYYY Has there been any medical treatment?* Yes No Please describe the medical treatment.*Are there any witnesses?* Yes No Witnesses (describe knowledge and provide contact information)*Other Evidence (Be prepared to provide copies of any other documentation)*How have you been financially damaged (both monetarily and non-monetarily)?*Do you have any prior litigation experience?* Yes No Please describe prior litigation experiences*Have you ever been terminated or forced to resign employment?* Yes No Please describe what happened.*Additional InformationHave other attorneys worked on this matter?* Yes No Who was the other attorney who worked on this matter?*
