EMPLOYMENT DISCRIMINATION/WRONGFUL DISCHARGE

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*Email:*

*Your Name:*

*Date:*

Name of employer: (This name can be withheld at this time, if you prefer.)

*Approximate number of employees working for this employer:*

*Your complaint:*

*Do you have any witnesses who will testify?*

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

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

*Were you terminated?*

Date of termination (if applicable):

*Date of hire:*

*Last job title (or position):*

*Reason (or reasons) why you feel you were terminated:*

*Union member?*

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

*Home phone number:*

Work phone number:

Other phone number:

*Your mailing address ( street, city, st, and zip ):*

When and how did you hear about us?

Your information is being sent directly to Burkhalter, Rayson & Associates, P.C., and by law, all communications to us are 100% confidential.

*There is no charge for us to review this inquiry and on most cases, we do not get paid unless we win.