Employment Law Intake Form Please complete the form below. General InformationFull Legal Name(Required) First Last Phone Number(Required)Email(Required) How were you referred to us?(Required) General Information Regarding the Employer Who Violated Your RightsThe below questions seek information only regarding your employment with the employer who violated your rights. This employer will be referred to as the "Defendant" in this intake form.Name of the employer (Defendant) who violated your rights?(Required) Name of your immediate supervisor while working for the Defendant?(Required) First Last Address of the location where you worked.(Required) Street Address Address Line 2 City State ZIP Start date with the Defendant.(Required) MM slash DD slash YYYY If applicable, on what date did you stop working for the Defendant? MM slash DD slash YYYY Job title with Defendant.(Required) Salary(Required) Did the Defendant require you to sign an arbitration agreement(Required) Yes No Unknown If you no longer work for the Defendant, did you sign a separation agreement? Yes No During your employment with the Defendant, had you ever received written warnings?(Required) Yes No While working for the Defendant, did you ever suffer a work-related injury?(Required) Yes No DiscriminationOnly answer this section if you believe you experienced discrimination at the workplace. If this does not apply, please skip to the next section. Identify the reason you believe you were discriminated against (check all that apply). Race Religion Pregnancy Sexual Orientation National Origin Ethnicity Disability Gender (includes sexual harassment) Age Marital Status Provide a description of the discriminatory conduct you were subjected toDid you ever complain about the discriminatory conduct? Yes No Whistleblower RetaliationOnly answer this section if you believe you believe the Defendant retaliated against you because you engaged in whistleblowing activity. If this does not apply, please skip to the next section. Describe the illegal conduct you complained about.Regarding your whistleblowing, please list the dates of all complaints as well as the names and job titles of all individuals you complained to.
