EMPLOYMENT LAW QUESTIONNAIRE

The information you provide on this will be held in strict confidence. Thank you for providing complete and thorough answers to all of the following questions, so that PEJOT WILSON LAW may consider your case for an in-office consultation.

Please note that submitting this form does not create a contract for representation by PEJOT WILSON LAW. Legal representation requires an in-person visit and the signing of a legal retainer or representation agreement after the firm has ensured that no conflicts of interest exist.

PERSONAL/CONTACT INFORMATION

Full Legal Name:
Street Address:

City:

State:

Zip:

Telephone Numbers

Home:

Business:

Cell/Pager:

Fax:

Date of Birth: (mm/dd/yy)

Spouse’s Name:

If spouse’s contact information is not the same as above, please list below:

Spouse’s Street Address:

City:

State:

Zip:

EMPLOYMENT/CONTACT INFORMATION

Hourly or Salary:

Salary/ hourly rate:

Number of employees at this location:

Hours worked per week:

Date of Hire:

Date of Termination (if applicable):

Employer’s stated reason for termination (if applicable):

Your reason for resigning (if applicable):

List any evidence of unlawful discrimination / harassment by your employer:

Please check any category or categories below that best identify the areas of concern you have regarding your employment:

Sexual Harassment	Race	Disability	Gender
Religion	Age	Retaliation	National Origin
Pregnancy	Your opposition to illegal activity	Non-Competition Agreement	Other Employment Contract
Medical Leave	Overtime	Unemployment	Other

Please explain “WHY” for each box you have checked:

Did you file for unemployment: YES NO

Have you been approved for unemployment? YES NO

Did your employer evaluate you on a regular basis? YES NO

If yes, were these evaluations favorable? YES NO

Please explain any unfavorable evaluation comments:

Did you receive verbal or written warnings while employed? YES NO

Is a physician, psychologist, or psychiatrist currently treating you? If yes please explain below.

Use the space provided below for any final comments you feel may be relevant to your employment and subsequent termination or resignation:

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