Address (Street Address):
Date of Birth:
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?
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:
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:
Where did you hear about Florin Roebig?