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How did you hear about us? *


Attorney Referred to


Date of Birth

SS No.

Work Phone

Home Phone

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Fax

Employer in Question

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Your Position

Your Salary

Your Supervisor's Name

Length of your employment

Number of Employees

Reasons given to you for termination/demotion

Hire date
Termination date

Describe your work record

Type of claim (check all that apply)
Sexual harassment
Race Discrimination
Gender Discrimination
Age Discrimination
Disability Discrimination
Religion Discrimination
Retaliation
Breach of employment contract
Non-competition agreement
Worker's compensation retaliation
Review of Severance Agreement
Health insurance and other benefits
FMLA
Whistleblower

Have you filed a charge of discrimination either with the Equal Employment Opportunity
Commission or the Texas Commission on Human Rights?
Yes
No
If so, when?

Have you received a "Right to Sue" letter?
Yes
No
If so, when?

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