Wrongful Termination Contact Form

Name

Email Address

Phone Number

Business Phone

Cellular or Pager

Address

City

State

Zip

Business or former employer name and address, including county.

What type of business is it? (sole proprietorship, LLC, etc.)

Have you used any other personal or business name(s) in the last six years?
Yes  No 

If yes, please list here:

If you are representing a business, please state your relationship to the business. (owner, manager, supervisor)

If you are representing yourself, what position did you hold prior to termination?

Name of immediate supervisor:

Please describe the wrongful termination issue in question:

Does the claim involve discrimination?
Yes  No 

If yes, please describe the discriminatory treatment:

If the discrimination relates to age, please provide us with your age:

Are you over 40 years of age?
Yes  No 

Please list any disabilities which employer was aware that you suffer from:

If the discrimination relates to race or national origin, please list your race or national origin:

If the claim relates to allegations of invasion of privacy, please discuss the circumstances surrounding the allegations.

If the claim involves disparate wage treatment, please provide:

Wages you were paid for the period involved:

Wages you felt you should have been paid:

Wage paid to others working performing same or similar tasks with similar training or experience:

Does your claim relate a violation of your collective bargaining rights?
Yes  No 

Are you a union member?
Yes  No 

If yes, please provide:

Name of union:

Member identification number:

Name of union representative:

Contact number for union representative:

Special concerns:

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