* Full name:
Home address:
Home phone:		Business phone:
Cellular phone:		Pager:
* E-mail address:
Place of birth:		Birth date:
Are you presently married?
Name of spouse:

Children? If so, names and ages:

2. Employment History
In this section, you should provide the information regarding the employer that you believe discriminated against you.

Discriminating Employer: (employer who allegedly discriminated against you)
Employer's Complete Address:
Employer's phone number:
Number of employees in your state:
Number of employees in other states:
Ending date of job:		Beginning date of job:
Job title:
Beginning pay (per hour or per year):		Ending pay:
Estimated hours of OT per week (hourly only):

How many hours a week do you work, on average?

Are you considered an exempt employee by your employer?
  

Are you paid overtime, or given any compensation for working more than 40 hours per week?

Immediate supervisor's name/title:

Are you a member of a labor Union? If so, what:

As part of this job, were you required to attend any type of binding arbitration to resolve any employment disputes? Yes No

3. Allegations of Discrimination:
Why do you believe your employer discriminated against you? (check one or more of the following):
Race Age Religion Gender/Sex Nationality Disability

If you checked disability, please describe the disability that you have:

Describe in detail below each incident that occurred while you were working for this employer that you believe was discriminatory. You must provide as much detail as possible. An incident can include just a comment being made by an employee or any actions taken against you by the company, your supervisor, or an employee. This could also include any instance where you believe you were treated differently than any other employee because of the above-cited reason for discrimination. Under sections a through g under this question, please number each incident. For example, your incident number #1 should have this same incident number when providing information about that incident under sections a through g.

a. Description of Incident (who was involved, their job title):

b. Any comments, jokes, or other actions that you believe were discriminatory that were part of this incident (made by whom):

c. If the incident involves being treated differently than another employee, please describe the circumstances and the name/position of the other employee(s) being treated differently:

d. The names of any witnesses to the incident and their positions:

e. The date such conduct occurred (to the best of your recollection):

f. Did you report this conduct to any person in the company? If so, what person, when, what happened:

g. Do you think the company retaliated against you in any manner for reporting the incident? If so, explain how:

4. Job Performance:
Did you have performance reviews conducted while employed? If so, state each date a performance review was conducted (annually, etc.), state who provided you the review and their job title, and give a general statement as to whether it was a good review. You should describe any performance issues that were raised in each review:

Were you ever suspended, punished, or terminated before by this employer? If so, describe:

5. Termination:
If you were terminated by this employer, please describe in detail the meeting that was held (or conversation) when you were terminated. This should include the date, who was present and their position, who terminated you and their position, and any reasons that were given for the termination:

6. Resignation:
If you resigned from this employer, please state the reasons why you resigned:

Date of resignation:

7. Charges of Discrimination:
Have you filed any charges of discrimination relating to any of the above described incidents with either the Equal Employment Opportunity Commission (EEOC), a State Commission on Human Rights, or City Human Rights Commission, or any other governmental agency? If so, when were they filed:

Name of Agency:

8. Employers BEFORE the one listed in question #2:
This will be information for employer(s) that you worked for prior to the employer that you believe discriminated against you.

Employer's Name:
Employer's address:
Ending date:		Beginning date:
Job classification:
Beginning pay:		Ending pay:
Reason(s) for leaving:
Immediate supervisor's name/title:
Employer's Name:
Employer's address:
Ending date:		Beginning date:
Job classification:
Beginning pay:		Ending pay:
Reason(s) for leaving:
Immediate supervisor's name/title:

9. Employers AFTER the One Listed in question #2:
This would be information regarding employers you worked for after you left the employer who you believe discriminated against you.

10. Places You have applied for Employment Since Leaving Discriminating Party: List all the places you have applied for employment, but did not receive employment, since leaving the employment of the place identified under #2.

Employer's Name:
Employer's address:
Date you applied:
Job applied for:
Beginning pay:
Name/title of person you interviewed with:
Reason provided for not obtaining job:
Employer's Name:
Employer's address:
Date you applied:
Job applied for:
Beginning pay:
Name/title of person you interviewed with:
Reason provided for not obtaining job:
Employer's Name:
Employer's address:
Date you applied:
Job applied for:
Beginning pay:
Name/title of person you interviewed with:
Reason provided for not obtaining job:

11. Educational Background
What education have you had, including any special job training (list high school, college, college courses, degrees, etc. and dates of each of these):

Dates that each education was received:

12. Other lawsuits:
If you were a party to another lawsuit in your life (this is only where there was formal court proceedings), including divorces and claims for workers compensation, state the nature of the lawsuit, what Court it occurred in, what date was the lawsuit filed, and the outcome:

13. Criminal History:
Other than speeding and parking tickets, state any incident that you were charged with any criminal violation, when this occurred, where it occurred, and the outcome (i.e. plea agreement, conviction):

14. Medical Care:
If you have seen any doctor, counselor, psychologist, or other health care provider for any reason relating to you allegations of discrimination, please provide the following: Name of health care provider, address, dates that he/she was seen, reasons for seeing this person:

Thank you for completing this information. Please sign and date below. I hereby state that the above information that I have provided is true and correct to the best of my knowledge and belief.

Possible Client's Signature:

Date: (printed form only)

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