Tell Us About Your Claim Employment - Initial Intake Form Attorney-Client Privileged Document. Law Offices of Jill P. Telfer. Step 1 of 6 - Personal Information 16% Name* First Last Email* Enter Email Confirm Email Address* Street Address City State / Province / Region ZIP / Postal Code Home PhoneCell PhoneBirth Date* Previous Names/Aliases Referred by Date Notified of Adverse Action: Date Effective Date of Hire* Title At Time of Hiring*Date of Termination and/or Last Adverse Act/Title*Salary at Hire*Salary at Termination*Supervisor at Termination*Who was involved in decision to terminate you?*Period of Unemployment?*Union?*YesNoType of Action Termination Failure To Reasonably Accommodate Failure To Promote Demotion Failure To Hire Denial of Equal Pay Sexual Harassment Wage and Hour Pregnancy FMLA/CFRA Other Type of Discrimination Sex Race Age Religion Physical Disability Mental Disability Medical Condition Sexual Orientation National Origin Marital Status Retaliation Other Name of Potential Defendant/Employer* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Type of Business Approximate Number of EmployeesLocation of Headquarters*Type of OrganizationName of Co. on PaycheckParent/SubsidiariesPotential Individual DefendantsNamePosition Present EmployerDate Employed SalaryPosition HeldOther Economic Loss? What event caused you to contact any attorney? (Failure to hire, layoff, wrongful termination, failure to promote, failure to reasonably accommodate, discipline, harassment, discrimination, etc.)* Reason given for adverse action (for example, termination, discipline, failure to reasonably accommodate, etc.)* What do you believe was the true reason?* Were other employees treated differently/better than you? (give specific examples)* Other facts suggesting discrimination/retaliation (e.g., discriminatory remarks, admissions) or unfair treatment* If you were terminated, what were the circumstances? Include who was present, what was said, and any prior warning* Who were witnesses to any problems in the work place? List names and positions* Will the witnesses be willing to speak with Law Offices of Jill P. Telfer?*YesNoDid you ever complain to your employer about the treatment you received? If so, when, and what did you do?* Did you have a written contract for employment?*YesNoDid the Company have written personnel policies or an Employee Handbook?*YesNoAt-will or good cause requirement?*If unsure please type unknown.Did the company use progressive discipline?*YesNoDid you receive written performance evaluations? What do they say?* Have you ever been disciplined by your employer? If so, please provide detail.* Did you sign an arbitration agreement?*YesNoDo you know who replaced you? If so, who? Have you ever been a party to litigation? If yes, please explain:* Have you ever been involuntarily terminated from a previous employer? If yes, please explain:* Have you ever filed an administrative claim with a State or Federal government agency? If yes, please explain:* Have you ever been arrested? If yes, please explain:* Have you ever been charged with a misdemeanor and/or felony? If yes, please explain:* Have you ever filed for bankruptcy? If yes, please explain:* Are you currently seeking medical treatment (physical and/or mental) as a result of your employment situation? If yes, please explain:* Do you have a “My Space” web site, or other public access website, including Facebook, LifeJournal, MyCyberSpace, Xanga, or something similar? If yes, please provide the url for the homepage. Do you maintain a blog? If yes, please provide the url.Do you have any IM (instant message) accounts? If so, list the “account name” for each IM account, and the provider:How many email accounts do you have? Please list each account: How did you learn of Law Offices of Jill P. Telfer?* Have you spoken or met with any other attorney concerning your employment matter? If so, please explain:* Are there any special circumstances that you think require immediate attention? If so please explain:* Please provide any other information that you think we need to evaluate your case:*
