EMPLOYEE INFORMATION

Name

Personal Email Address

Phone (non work)

Peronsal State of Residence & Address

EMPLOYER INFORMATION

Employer Name

Overall Number of Employees

Geographic Location of Employment (city and state)

Job Duties

Other

Still Employed?

Still Employed

If not, last date of employment?

Were you terminated or did you resign?

If terminated what was the reason

Nature of Assistance Sought

Does this regard an employment contract?

If so what type of contract? (New Hire Employment Contract, Non Compete Agreement, Non Solicitation Agreement, Review Former Employment Contract, Severance Agreement, Other (specify below))

Does this regard an employment contract : Other

Does this regard potential retaliation?

If so what type of contract? (IE: New Hire Employee Agreement, Non Compete Agreement, Non Solicitation Agreement, Review Former Employee Contract, Severance Agreement, Other (Please specify below))

Other (type of contract)

If so what type? (IE: External Complaint, Filing a claim, Internal Complaint, participation in investigation/proceeding))

Other (What type of retaliation)

Date of Birth

Race or Nationality

Serious Health Condition or Disability

Date of Adverse Job Action

Brief Summary of Facts