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First & Last Name *

Email *

Phone *

Street Address *

City *

State *

ZIP Code *

Date of Birth *

Sex *MaleFemale

Ethnicity *White/CaucasianBlack/African-AmericanAsianEast IndianHispanic/LatinoMiddle EasternNative AmericanPacific IslanderMulti-EthnicOtherfor purposes of evaluating potential discrimination

How did you hear about Florin|Roebig? *

Please name the employer you are contacting us about *

What is/was your job title/position at this employer and what were your job duties? *

What is/was your salary/wages? *

How many employees work/worked at your location? At your employer as a whole? *

What were the dates of your employment (start and end date)? *

Do you feel you were discriminated against? If so, on what basis? (sex, race, age, religion, national origin, disability, pregnancy, FMLA) *

Did you ever object to or report illegal activity engaged in by your employer? If so, do you feel you were retaliated against for same?

Did you ever request medical leave or disability-related accommodations from your employer? If so, were they granted?

Please describe the issue you had/are having with your employer which has prompted you to seek legal representation, including all relevant dates and names: *

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? *EmployedResignedTerminated

If you were terminated or forced to resign, who terminated you and what was their position, age, sex, and ethnicity? *

If you were terminated, what was the reason your employer gave you? *

Has your position been filled? If so, what is the age, sex and ethnicity of your replacement? *

Are there any individuals that may be able to provide information relevant to your claim? *YesNo

Name of Individual

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