Case Submission - Discrimination & Wrongful Termination

Your Information:
*First Name:
*Last Name:
*E-mail:
*Telephone:
Street Address: Apt No:
City/State/Zip:
Employer Information:
Employer Name:
Street Address:
City/State/Zip:
Type of Business:
Number of Employees at your location:
Total Number of Employees in the company:
Information about your Case:
Your Position:
Your Duties:
Salary/Wages: per hr. per mo. per yr.
Your Start Date:
Were you Terminated or did you Resign: When?
Have you been working since then?
Your New Employer:
Your New Start Date:
Your New Salary:
Your New Position:
Did you have a written Contract?
Do you feel that you are/were the subject of discrimination?
If so, was the discrimination on the basis of:
Why do you believe you were the subject of discrimination?
Was there sexual or racial harassment going on in the workplace?
If so, please provide the details:
Do you believe you were terminated in retaliation for some action related to your employment?
If so, Please provide the details:
Do you feel you were terminated because you knew about illegal or improper conduct by your employer [i.e. whistle blower]?
If so, please provide the details:
What was your employer's reason for your termination?
Did your employer claim reorganization or layoff due to reduction in workforce?
Did your employer hire new employees after the alleged reduction in the work force?
In your opinion, what is the real reason for your termination?
Please provide summary of the events leading to your termination:
Have you filed an internal grievance?
If so, what did your internal grievance state, when did you file and with whom?
Were you a member of a Union?
Have you filed a Union grievance?
If so, what was the result of your Union grievance?
Have you filed a complaint with the
If so, what is the status of your complaint?
Did you receive any written or oral warnings about your work? Describe.
Please provide the following details about your replacement if known. If no one replaced you, please write 'none'.
Name
Age
Gender
Race
Seniority
Experience
Additional Information about your Case:
In the course of termination, what documents, if any, did you sign?
Did you accept any severance pay?
Please include any additional comments you may want to include:
Have you had or do you have a myspace page, blog, or any other personal webpage?
If so, please identify the URL where that page or pages can be found.
How did you learn about us?
If none of the above, please describe how you found out about us.