Date of Birth*
Date of Hire*
What was rate of pay?*
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Date of Adverse Employment Action*
Adverse Employment Action Taken*
TerminatedDemotedFailure to HireOther
Reason given by Employer for Adverse Action*
Reasons you feel were behind the Adverse Action*
Because of my ageBecause my genderBecause of my disabilityBecause of my religionBecause of my nationalityBecause my doctor won't let me return to work at the end of my leave periodBecasue I filed for Workers' CompensationBecause I was falsely accused of wrongdoingBecause I filed a complaintBecause of a personal disagreement I had with my supervisorOther (describe the reason for the action)
Please explain/describe the circumstances for any of the above reasons that apply to your situation
Have you filed a complaint with any agency?*
If 'Yes', which Agency?
Have you received a ruling or decision?*
If 'Yes', please state the ruling or decision.
What losses have you suffered?*
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(Lost wages- how much; lost bonuses/commissions;lost benefits; other)
Do you have an employment contract?*
Are you represented by a union?*
Have you applied for unemployment benefits?*
Yes No Not Applicable
Have you obtained other employment?*
If 'Yes', where?
If you have obtained other employment, what is your new Job Title?
If you have obtained other employment, what is your new rate of pay?
How did you learn about ELLIOT MORGAN PARSONAGE, PLLC?