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Employment Information
Date of Hire:
*
MM slash DD slash YYYY
Date of Termination:
*
MM slash DD slash YYYY
Occupation / Job Title:
*
Gross annual income:
*
$25,000 or Less
$25,000 – $50,000
$50,000 - $99,000
$100,000+
The employer has the following number of employees:
*
Under 10
11-25
26-50
51-100
101+
Employment Issue?
Employment Issue?
Harassment
Discrimination
Wrongful Termination
Retaliation
Other
Do you have a case
First Name
*
Last Name
*
Email
*
Phone
*
Tell us about your case
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