Employee Law Intake Form

Name *

First

Last

Email *

Phone *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of birth

Emergency contact name & relation

Emergency contact phone number

Employer

Employer location

Approximate number of employees

How long have you worked there?

What was your job title or position?

How much were you paid? Per hour or annually?

Were you terminated? When?

If you were not terminated, what negative action was taken against you and when?

Describe the termination/negative action and why you believe it happened.

Comment or message *