Contact | The Linesch Firm

Employee Information

Name*

First
Last

Date of Birth*

MM

DD

YYYY

Sex

Address*

Street Address
Address Line 2
City

State
Zip Code

Email*

Home Phone*

Cell Phone

Fax Number

Marital Status

Spouse's Name

First
Last

Employer Information

Name of Employer*

Type of Business*

Address*

Street Address
Address Line 2
City

State
Zip Code

Position*

Hours Worked per Week*

Hourly or Salary Employee*

Rate Per Hour

Annual Salary

If Commission, What are your approximate W-2 Earnings?

Number of Employees at this Location*

Briefly describe your job duties and responsibilities.*

If hourly employee, has employer always paid you for all hours worked and overtime (that is 1 1/2 times your usual pay) for all hours over 40 per week?

Yes
No
Not Applicable – I’m Exempt

Date of Hire*

MM

DD

YYYY

Are you currently employed?*

Yes
No

Date of Termination or Resignation*

MM

DD

YYYY

Date notified of termination, if different than termination date

MM

DD

YYYY

Employer's Stated Reason for Termination, or Your Reason for Resignation*

Were you given a separation package that needs to be reviewed?*

Yes
No

Did you receive any severance?*

Yes
No

If yes, how much did you receive?

Did you sign a release for this severance?

Yes
No

Please provide a brief summary of your employment situation and/or why you feel your separation from this employment was wrong/illegal.*

From the category(ies) below, please choose which best describes your treatment:*

Other – Please explain:

Explain "why" concerning all the boxes you have checked above.

Have you filed for Unemployment Compensation?*

Yes
No

Approved for Unemployment Compensation?*

Yes
No

Were you evaluated on a regular basis? If yes, were the evaluations favorable?*

Did you receive any verbal or written warnings while employed? If yes, please provide details.*

Are you currently being treated by a Physician, Psychiatrist, or Psychologist? If yes, please explain

Have you been terminated by a previous Employer? If yes, what were the circumstances?

Have you ever filed a discrimination claim with any Agency or Court regarding any previous employment? If yes, please state the approximate date, location, and circumstances.*

Have you ever been involved in a lawsuit? If yes, what were the circumstances?

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

How did you hear about us?

Name of former client:

Name of attorney:

Other – Please explain:

We will contact you immediately after reviewing your completed questionnaire.