Employment Case Intake Form

We would like you to complete this Initial Consultation Form in order to assist us in evaluating your case. Reviewing your Consultation Form does not mean that Wagner, Jones, Kopfman & Artenian LLP has agreed to act as your attorneys. We are agreeing only to evaluate the facts presented in your Consultation Form responses to determine whether we can assist you.

Your Email

Name:

Referred By:

Home Address:

City:

State:

Zip Code:

Date of Birth:

Home Phone:

Work Phone:

Cell Phone:

Pager:

Employer against whom you have a complaint:

Address:

Phone:

Job Title:

How many full time employees at the workplace?

Date of Hire by employer against whom you have a complaint:

Date of Termination:

Voluntary?
yesno

Salary/Wage:

What do you believe was the reason for your termination?

What reason was given to you for your termination (if in writing, provide a copy)?

Nature of Complaint:
Sexual HarassmentSex DiscriminationRacial DiscriminationReligious DiscriminationPregnancy DiscriminationAge DiscriminationNational OriginWrongful TerminationRefusal to do Illegal ActWhistle BlowerWage/Overtime ClaimFamily Medical Leave ActDisability/MedicalDiscrimination

Name & position of employee(s) who discriminated or harassed:

Names and Addresses of witnesses to acts:

Other Victims:

Date harassment/discrimination began:

Date harassment/discrimination ended:

Date you first complained to management:

To whom did you complain/job title & name:

What happened after you complained?

Was complaint in writing?
yesno

Have you ever been promised permanent employment?
yesno

By whom?

Job Title?

Present Employer:

Current Rate of Pay $

Have you, or do you plan to file bankruptcy?
yesno

Have you filed a charge with the Department of Fair Employment and Housing, Equal Employment Opportunity Commission, Department of Labor, or Labor Commissioner?
yesno

If yes, which agency & date charge filed:

Have you received a "Right to Sue" letter from any agency?
yesno

If yes, with whom and when:

Do you know of any illegal action(s) your employer engaged in?

yesno

If so, explain the illegal action:

Was there any written agreement with your employer? (If yes, provide a copy)
yesno

Were you a member of any union while on the job?

yesno

Did you receive letters of commendation, accolades, awards, performance bonuses, or disciplinary notices, warnings, demotions? (If so, explain in detail)
yesno

Do you have a claim for unpaid meal time, over time, vacation time, sick time or breaks?
yesno

Did you ever work more than 40 hours a week and not get paid overtime?
yesno

Please give a brief statement explaining in detail the facts that form the basis for your complaint against your current/former employer (provide witness statements if available):

I acknowledge and understand that Wagner, Jones, Kopfman & Artenian LLP are not my attorneys and have not undertaken representation at this point.

I Acknowledge

Date:

Your Message