First Name*

Last Name*

E-mail*

Telephone*

Street AddressApt No

City/State/Zip ---ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWADCWVWIWY

Employer Name

Street Address

City/State/Zip ---ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWADCWVWIWY

Type of Business

Number of Employees at your location

Total Number of Employees in the company

Your Position

Your Duties

Salary/Wages per hr. per mo. per yr.

Your Start Date

Were you Terminated or did you Resign:---ResignedTerminatedWhen?

Your New Employer

Your New Start Date

Your New Salary

Your New Position

Do you have a written Contract?---YesNo

Do you feel that you are/were the subject of discrimination?---YesNo

If so, was the discrimination on the basis of---RaceEthnic GroupGenderAgeDisabilityReligionSexual OrientationOther

Why do you believe you were the subject of discrimination?

Was there sexual or racial harassment going on in the workplace?---YesNo

If so, please provide the details

Do you believe you were terminated in retaliation for some action related to your employment?---YesNo

If so, Please provide the details

Do you feel you were terminated because you know about illegal or improper conduct by your employer [i.e. whistle blower]?---YesNo

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?---YesNo

Did your employer hire new employees after the alleged reduction in the work force?---YesNo

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?---YesNo

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

Are you a member of a Union?---YesNo

Have you filed a Union grievance?---YesNo

If so, what was the result of your Union grievance?

Have you filed a complaint with the---Department of Fair Employment and Housing (DFEH)Equal Employment Opportunity Commission (EEOC)No complaints filed

If so, what is the status of your complaint?

Did you received 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

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 Web page? ---YesNo

If so, please identify the URL where that page or pages can be found.

How did you learn about us?---Angie's ListBackpage.comCitySearchCraigslistGoogleLawyers.comMSNRecommendationYahooYellow PagesNone

If none of the above, please describe how you found out about us.

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