Protecting Workers From Wrongful Employment Practices

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First Name *

Last Name *

Mailing Address *

City *

State *

Postal Code *

Email *

Phone Number *

Cell Phone (for text messages) *

Best way to contact you: *

Email Phone

What service are you interested in?

What kind of company do you work for?

Approximately how many people work for your company? *

What is/was your job title? How long were you in that position?

In what state do you work? *

What happened? *

Are you still at work?

Yes No

If you are no longer at work, what was your last day?

Were you able to find another job? When?

What reason did your employer give you to justify the firing?

Do you have a non-compete or non-solicitation issue? Describe:

What do you think is the real reason the company fired you?

I reported wrongdoing to HR or my boss

Yes No

When did you make the report?

Was the report in writing?

Yes No

When you reported wrongdoing, what did you say?

Annual salary

Were you referred by someone?

Having trouble with this form? Or just prefer to talk to someone? For help call 202-449-8527 .