Law Offices of Eric P. Oren, Inc.

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Employment Case - Questionnaire

Note: This questionnaire is submitted for review by the Law Offices of Eric P. Oren, Inc. (hereinafter referred to as ATTORNEY) The submission of information is for review only. The attorney does not represent you in your legal matter unless and until a formal written Retainer Agreement is signed by both you and the attorney. No decision or guarantee has yet been made on whether the attorney will accept your case. Further additional information may be requested in order for the attorney to reach a decision. Please note that it takes time to review the material submitted and to make any reply or decision. The Law Offices of Eric P. Oren, Inc. will attempt to respond in writing to your request for representation as soon as possible. Please allow 5 days for our office to respond to your request prior to calling our office to followup on your request for representation.

Background Information

Name:

Date:

Address:

City:

State:

Zip Code:

Home Telephone:

Work Telephone:

Cell Phone:

Email Address:

Birth Date:

Referred By:

Potential Defendant Employer:

Name:

Street Address:

City:

State:

Zip Code:

Approx. # of Employees

Type of Business:

Salary: $

Hire date:

Position Held:

Union?

Did you resign?

Date of resignation:

Reason given for termination (If you resigned please explain your reason given, if any):

Did you quit without notice?

Date:

Have you applied for unemployment?

Are you receiving unemployment?

Were you denied unemployment?

Are you receiving disability?

Describe your disability:

List the Reason(s) for which YOU BELIEVE you were terminated:

Who notified you of your termination?

Were you given a termination letter?

Did you sign any written document to receive severance pay?

List all employer discipline (including verbal warnings) during your Employment:

Did you file a union grievance?

Did you have an employment contract?

Was your employment At-Will?

Did you sign an agreement to arbitrate all claims of discrimination against your employer?

Did your employer have a policy manual?

Do you have a copy of your employer's policy manual?

Type of Discrimination You Believe You Were Subjected To:

Failure to Promote

Race

Demotion

Age

Religion

Denial of Equal Pay

Disability

Sexual Harassment

Sexual Orientation

Other (describe the nature of the discrimination, harassment or other wrongful conduct you were subjected to and the date(s)):

List all witnesses that may be able to support your claim of wrongful:

Termination/discrimination claim:

Did you complain to any supervisor regarding harassment/discrimination? If so, list approx. Date, names and substance of complaint and whether in writing or not:

Present Employer

Name:

Date Employment began:

Salary:

Position Held:

Other Economic Loss caused by your termination?

Administrative Action:

Have you filed:

Union Grievance?

Date of hearing held:

Type of hearing held:

Have you filed any complaints with any of the following:

EEOC

Right to Sue letter issued?

DFEH

Right to Sue letter issued?

Internal complaint to human resources dept. et.:

Workers Comp. Claim filed?

Were you injured on the job?

Was there retaliation for filing a workers compensation claim? Explain:

Was there retaliation for taking a leave of absence?