Name * PHONE * Email * ADDRESS DATE OF BIRTH * WHAT IS THE BEST WAY TO CONTACT YOU? * NAME AND ADDRESS OF EMPLOYER AT ISSUE * HOW MANY EMPLOYEES OF EMPLOYER AT ISSUE? * DATE OF EMPLOYMENT WITH EMPLOYER AT ISSUE:
A. START DATE * B. END DATE HAVE YOU FILED AN EEOC CHARGE? * HAVE YOU RECEIVED A RIGHT TO SUE NOTICE FROM THE EEOC? * LAST SALARY WITH EMPLOYER AT ISSUE * FRINGE BENEFITS:
PLEASE DETAIL ANY BENEFITS YOU RECEIVED, INCLUDING BUT NOT LIMITED TO HEALTH, VISION, DENTAL, 401K, AND/OR DEPENDENT COVERAGE * PROMOTIONAL/DISCIPLINARY HISTORY:
A. PLEASE DESCRIBE YOUR PROMOTIONAL HISTORY WITH THE EMPLOYER * B. PLEASE DESCRIBE YOUR DISCIPLINARY HISTORY WITH THE EMPLOYER AT ISSUE * NATURE OF DISPUTE:
A. PLEASE DESCRIBE IN DETAIL THE CIRCUMSTANCES LEADING TO AND SURROUNDING YOUR DISPUTE * B. IF TERMINATED/DISCIPLINED, WHAT WAS THE REASON STATES FOR THE TERMINATION/DISCIPLINE? PRIOR OR CURRENT LAWSUITS:
HAVE YOU BEEN INVOLVED IN ANY PRIOR LAWSUITS OF ARE CURRENTLY INVOLVED IN ANY LAWSUITS(INCLUDING BANKRUPTCY FILINGS)? * IF SO, PLEASE SPECIFY THE COURT, CASE NUMBER, SUBJECT MATTER, AND FINAL DISPOSITION MEDICAL HISTORY:
A. PLEASE LIST ALL DIAGNOSED MEDICAL CONDITIONS THAT RELATE TO YOUR DISPUTE * B. PLEASE LIST ALL MEDICATIONS/PRESCRIPTIONS YOU CURRENTLY TAKE THAT RELATE TO YOUR DISPUTE * CRIMINAL:
PLEASE DETAIL ANY ARRESTS, INDICTMENTS, AND/OR CONVICTIONS * ANY OTHER RELEVANT INFORMATION? HOW DID YO HEAR ABOUT THE COLES FIRM P.C.?