Employment Questionnaire

Check all boxes that may apply:

Discrimination because of my race, religion, national origin, age, disability or gender (sex).
Sexual harassment.
Unwelcome physical contact or touching.
Failure to pay overtime.
Wrongful termination.
Termination because of filing a worker's compensation claim.
Other claim.

Information about you:

Name
Address City & State
E-mail
Phone
Age
Race
Religion
National Origin
Disability Status	Not Disabled Disabled
Injury Status	Have you recently been injured?

Information about the problem employer:

Company Name
Company Address City & State

Number of Employees
Supervisor's Name
Date of Hire
Date of Termination*
Reasons Given*

* if applicable.

Please Briefly Describe What Happened: