Employment Law Questionnaire

First Name(Required)

Last Name(Required)

Phone(Required)

Email(Required)

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer Name(Required)

Employer Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How many full-time employees does your employer have (best estimate)?(Required)

Your Job Title(Required)

Your Job Description(Required)

Date of Hire(Required)

Rate of Pay(Required)

Date of Adverse Employment Action(Required)

Adverse Employment Action Taken(Required)

Reason Given by Employer for Adverse Action(Required)

Reasons you feel were behind the Adverse Action

Please explain / descript the circumstances for any of the above reasons that apply to your situation(Required)

Have you filed a complaint with any agency?(Required)

Yes

If Yes – Which Agency?

Have you received a ruling or decision or notice of your right to sue?

Yes

If Yes – Please state the ruling or decision, and the date of the decision or notice.

What losses have you suffered?(Required)

(Lost wages- how much; lost bonuses/commissions;lost benefits; other)

Do you have an employment contract?(Required)

Yes

Are you represented by a union?(Required)

Yes

Have you applied for unemployment benefits?(Required)

Yes

Not Applicable

If Yes – Were you awarded benefits?(Required)

Yes

If No – Did you appeal?(Required)

Yes

If Yes – What is the status of your appeal?

Have you been offered a Severance Agreement?(Required)

Yes

Have you obtained other employment?(Required)

Yes

New Employer?

New Job Title?

New Rate of Pay?

How did you learn about ELLIOT MORGAN PARSONAGE, PLLC?(Required)

To which attorney in our office were you referred to (if any)?