"The labor of a human being is not a commodity or article of commerce."

—The Clayton Anti-Trust Act, 1914

(for wrongful termination claims)

If your potential claim involves discrimination because of race, sex, sexual harassment, pregnancy, age, disability/handicap, religion or national origin, please complete our questionnaire for Discrimination and Other 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:


    • 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
       

    • Briefly, describe why you feel your termination was wrongful.:


    • What severance were you offered?


    • Did you sign a severance agreement, or when is your deadline to sign an agreement?


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

      (Please note that our lawfirm handles all types of employment-related matters. We also handle cases involving personal injury or death resulting from negligence or defective products, as well as cases involving defamation, unfair insurance practices or assaults. If you know someone who could utilize our services, please refer them to us.)