Employment Wrongful Discharge Inquiry Form

Todays Date *

Name *

First

Last

Address (Street, City, State, & Zip Code) *

Email *

Contact Phone Number *

When is the best time to contact you, and how would you prefer we contact you?

Name of employer (If you prefer, this information can be withheld at this time)

Approximate number of employees working for this employer.

Do you have any witnesses who will testify?

Have you ever been written up or had a bad performance review? If so, please explain

Complaint Description

Were you discriminated or retaliated against? If so, please explain

Date of hire:

Were you terminated? .Yes or No

If so, what was the date of termination:

Reason (or reasons) given by employer for your termination:

If the above reason for termination is not true or the real reason, what do you think is the real reason for your termination?

Last job title (or position)

Union member?.Yes or No

How did you hear about us?

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