"Our duty to preserve the Seventh Amendment is a matter of high Constitutional importance. The founders of our country thought that trial by civil jury was an essential bulwark of civil liberty and it must be scupulously safeguarded."

—Justice Hugo Black, 1939

(for employment-related claims)

    • Please enter your full name:

      First Name
      Last Name
      Middle Initial
      Title
       

    • Please enter your full address:

      Street Address
      Address (cont.)
      City
      State/Province
      Zip/Postal Code
      County
      Country
       

    • Please enter your home, an alternate telephone number and e-mail address:

      Work Phone
      Home Phone
      Cellular Phone
      E-mail

    • Please enter your gender:

      Male  Female

    • Birth date:

      -- mm/dd/yy

    • Driver's License Information

      D.L. #
      State

    • Please provide the following information regarding the employer who took the
      adverse action against you:

      Name
      Street Address
      Address (cont.)
      City
      State/Province
      Zip/Postal Code
      County
      Country
      Phone

    • Please enter your job positions with the above employer, and the dates you held those positions:


    • How many employees does the employer have?


    • Please enter your dates of employment (beginning and ending, where applicable) with the above employer, or if you were denied employment, your date of application and date of denial:


    • Enter your ending wage or salary (e.g., per hour, per week, per year):


    • Please enter the full names and addresses of any witnesses who could support your claim:


    • Place a check next to the type of adverse personnel action to which you were subjected (choose all that apply):

      Termination         Failure to Hire
Retaliation         Demotion          
Wages               Denial of Leave
Failure to Promote  Job Assignment        
Other

    • Explain:


    • Place a check next to the type of discrimination you feel you have experienced (choose all that apply):

      Race                Sexual Harassment
Sex                 Age
National Origin     Religion
Pregnancy           Disability
Breach of Contract            
Family and Medical Leave            
Filing a Worker's Compensation Claim
Other

    • Explain:


    • Have you filed a charge of discrimination with the Equal Employment Opportunity Commission (EEOC)?

      Yes No

    • If yes, please enter the date filed:

      -- mm/dd/yy

    • Please give the EEOC charge number:


    • Have you received a notice of right to sue from the EEOC?

      Yes No

    • If yes, please give the date you received the right to sue:

      -- mm/dd/yy

    • Have you filed a charge of discrimination with the Texas Workforce Commission, Civil Rights Division (TWC)?

      Yes No

    • If yes, please enter the date filed:

      -- mm/dd/yy

    • Please give the TWC charge number:


    • Have you received a notice of right to file a civil action from the TWC?

      Yes No

    • If yes, please give the date you received the notice:

      -- mm/dd/yy

    • If terminated, please give the date you learned of termination:

      -- mm/dd/yy

    • What reason(s) were you given by the employer for the adverse personnel action taken against you (i.e., your termination, demotion, failure to hire, etc., as applicable)?


    • Do you believe this is a true reason?

      Yes No

    • If not, then what is the reason you feel caused the adverse personnel action?


    • Who took the adverse personnel action against you?

      Name
      Job Title
       

    • If you know, state the name, age, gender and race of the person who replaced you, if you were terminated:

      Name
      Race
      Age
      Gender Male Female
       

    • What were the results of any performance evaluations you received?


    • Were there ever any complaints about your work? If so, please explain:


    • Did you have a written or verbal employment contract or agreement with your employer? If so, please describe the terms:


    • Who referred you to our law firm?

      Name
       

    • Please tell us any other information you believe would help us in evaluating your
      claim: