Employment (Still with Employer)

Your Information

First Name*

Last Name*

E-mail*

Telephone*

Street AddressApt 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

Do you have a written Contract?

Do you feel that you are the victim of discrimination?

If so, was the discrimination on the basis of

Why do you believe you are the subject of discrimination?

Is there sexual or racial harassment going on in the workplace?

If so, provide details

Do you believe you are being retaliated against for some action related to your employment?

If so, Please provide the details

Do you feel you are being targeted because you know about illegal or improper conduct by your employer [i.e. whistle blower]?

If so, please provide the details

Date of last incident of discrimination/retaliation/harassment

Please provide a summary of the events leading up to the last incident

Did you file an internal grievance?

If so, what did your internal grievance state, when did you file and with whom?

Are 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?

Have you received any written or oral warnings about your work? Describe.

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 Web page?

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.

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Do I have a Case?