If a question does not apply to you, please enter “not applicable”. Name Phone Number Address (Street Address) City State Zip Email Address Date of Birth Sex FemaleMaleOther Ethnicity White/CaucasianBlack/African AmericanAsianEast IndianHispanic/LatinoMiddle EasternNative AmericanPacific IslanderMulti-EthnicOther Who is/was your employer? What is/was your job title/position and what were your job duties? What is/was your salary? How many employees work/worked at your location? At your employer as a whole? What were your dates of employment? Who hired you and what was their job title/position? Did your employer provide you with performance evaluations/feedback? If so, please describe them. Have you ever received any write ups or other disciplinary action by your employer? If so, please describe them, including the date(s) you received each write up or disciplinary action. Are you still employed, have you resigned, or have you been terminated? —Please choose an option—EmployedResignedTerminated If you were terminated or forced to resign, who terminated you and what was their position, age, sex, and ethnicity? What was the reason given for your termination? Has your position been filled? If so, what is the age, sex and ethnicity of your replacement? Please describe in detail the issues you have/had with your employer, including all relevant dates and names: If you’ve been terminated, have you found new employment? If so, please list the name of your new employer, your job title, the date you were hired, and your current income. Please list any individuals that may be able to provide information relevant to your claim, including whether they are a current or former employee, and what information they have: Referred by? Please leave this field empty.
