1. Phone Number

2. Email Address

Name and Additional Phone # (optional)

3. Employer: (General description will suffice)

4. # of Employees: (Approximate number will suffice)

5. Length of Employment:

6. Position:

7. Salary:

8. Do you contend you were wrongfully terminated? If so, provide the following information:

A. Date of termination:

B. Position of person who terminated you:

C. What reason were you given, if any:

D. If you disagree with the reason given, what do you believe was the cause of your termination?

E. Are you re-employed yet?

9. Do you contend you have been harassed or discriminated against? If so, provide the following information:

A. Position of person who has harassed or discriminated against you:

B. Does this person harass or discriminate against you because of your age, sex (including sexual harassment), pregnancy, race, religion, national origin, disability, sexual orientation? If so, which one:

C. If this person does not harass or discriminate against you because of one of the categories listed above, please provide a brief statement as to why you believe this person harasses or discriminates against you:

D. Have you reported the harassment or discrimination to any supervisor or manager? If so, provide the following information:

(1) Position of person receiving the complaint?

(2) Date the complaint was lodged:

(3) Was the complaint verbal or in writing:

(4) Provide a brief description of your employer's response to your complaint:

(5) Did the harassment or discrimination continue after your complaint?
yes no

E. Have you received a right to sue letter from either the DFEH or the EEOC?
yes no

If so, when:

10. Do you contend you are owed wages, commissions, or tips by your employer? If so, provide a brief description of why you believe this money is owed and the amount of money you contend is owed:

11. Do you contend you were improperly denied a medical leave? If so, provide a brief description of why you believe the denial was improper:

12. If your situation is not covered above, provide a brief description of facts relevant to your claim: