| Your Full Name |
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| Home Address |
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| Street Address |
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| City |
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| State |
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| Zip |
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| E-Mail |
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Phone Numbers -
Daytime and Evening |
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Employer's Name
Number of Employees |
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Job Title/
Description of Duties |
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| Date of Hire |
(Hire) |
| Dates on Which Your Employer Took Most Severe Adverse Employment Action Against You. |
Date Conduct Began:
Last Date of Conduct:
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| Nature of Adverse Employment Action Against You. |
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| Your Employer's Reasons for Advers Action(s). |
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Reasons You Believe that Your Employer's Conduct was Unfair or Unlawful, Including Any Facts to Show the Unlawful Reason and That the Employer's Reasons are Not True.
1. Please describe the "Who, What, When, Where, Why and How" of the Incidents.
2. Please Identify any Witnesses Regarding the Conduct or Actions About Which You are Complaining, as well as What They Witnessed. |
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Did You Have an Oral or Written Employment Contract? or
Where You told that You Would Only be Terminated for Just or Good Cause?
Did You Sign an Arbitration Agreement? |
Yes No (Contract)
Yes No (Told for Cause)
Yes No (Arbitration) |
Are you Employed Pursuant to a Union Contract (CBA)?
Was There an Employee Handbook? |
Yes No (CBA)
Yes No (Employee Handbook) |
| Date of Birth |
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| What Damages Have You Suffered to Date? |
Lost Wages
$ a Month for Months
Benefits (E.g., Bonus, Commissions, Health, Dental, Retirement, Etc.)
Other (Including Emotional Distress, Depression, Anxiety, Insomnia, Crying, Weight Change, Libido). If You Have Received Medical of Psychological Treatment, Please Identify The Types of Doctors, Medication and Treatment.
If Unemployed, Please Provide an Estimate of Future Unemployment?
If You Have New Employment, Please State Your New Comepnsation and Benefits?
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| Have You Filed Any Complaint with a Federal or State Agency or Court Concerning Your Employment or Termination (Including EDD, DFEH, EEOC & State Court, etc.)? |
Yes No (Complaint) |
| If You Have, PleaseState to Which Agenc or Courts? |
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| When did you file? |
(Date Filed) |
| Have You Received any Right to Sue Letter, Award or Ruling? |
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| When Did You Receive the Award, Ruling or Right to Sue Notice? |
(Date Received) |