WWD Employment Intake Form

Employment Intake Questionnaire: CONFIDENTIAL: ATTORNEY-CLIENT PRIVILEGED DOCUMENT

In order for us to have a better understanding of the ssues you are inquiring about, and whether or not we will be able to be of help to you, we would appreciate your filling out the questionnaire below and returning it to us according to the instructions below.

We will get back to you within 1 to 2 days of our receipt of your questionnaire. If your situation is truly an "emergency", please call (215) 656-3609 and let us know, and we will do our best to get back to you immediately.

Important Notices: By asking you to fill out and send in this Questionnaire, the law firm of Willig, Williams and Davidson is NOT agreeing to take any legal action on your behalf or to represent you in any way. Any agreement by this law firm to take any legal action for you must be agreed to in writing and signed by one of the attorneys at this firm. This document is NOT such an agreement.

Please be advised that in the event an initial consultation is scheduled with you, the fee for that consultation is $350 per hour, which is payable at the time of the consultation.

Your Name:

Street Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Cell Phone:

Home E-mail Address:

Best Time to Call:

Name of Company/Organization for Which You Worked, or Still Work:

Street Address of Company/Organization:

Company City:

Company State:

Company Zip:

Date of Hire at Company (MM/DD/YYYY):

Date of Birth (MM/DD/YYYY):

Job Title/Description:

Salary or Hourly rate of Pay

Briefly describe how you feel your employment rights were violated, or describe the issue about which you are presently concerned:

When (on what date) did the events described above occur:

Do you think you might have been discriminated against because of your Age? Sex? Sexual Orientation? Disability or History of Disability? Race? National Origin? Taking Family and Medical Leave Act (FMLA) Leave? Whistleblowing? Other Factor? If yes, please explain why:

Do you feel that your company violated the terms of the company’s employee handbook? If so, tell us what provision of the handbook you feel was violated?

Is there any other information that may help us understand why you feel your rights were violated by your employer?

Can you tell us how you feel you’ve been damaged by the action your employer has taken against you?

Are you a union employee?:

Is the opposing party a union?:

Are you a public employee?:

Was a grievance filed?:

What was the outcome of the grievance?

Were charges filed?:

If charges were filed, where were they filed?:

Have you ever been a party in a lawsuit?:

*Important Notices: By asking you to fill out and send in this Questionnaire, the law firm of Willig, Williams and Davidson is NOT agreeing to take any legal action on your behalf or to represent you in any way. Any agreement by this law firm to take any legal action for you must be agreed to in writing and signed by one of the attorneys at this firm. This document is NOT such an agreement.

Return to WWD Home Page

Your Name:
Street Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone:
Home E-mail Address:
Best Time to Call:
Name of Company/Organization for Which You Worked, or Still Work:
Street Address of Company/Organization:
Company City:
Company State:
Company Zip:
Date of Hire at Company (MM/DD/YYYY):
Date of Birth (MM/DD/YYYY):
Job Title/Description:
Salary or Hourly rate of Pay
Briefly describe how you feel your employment rights were violated, or describe the issue about which you are presently concerned:
When (on what date) did the events described above occur:
Do you think you might have been discriminated against because of your Age? Sex? Sexual Orientation? Disability or History of Disability? Race? National Origin? Taking Family and Medical Leave Act (FMLA) Leave? Whistleblowing? Other Factor? If yes, please explain why:
Do you feel that your company violated the terms of the company’s employee handbook? If so, tell us what provision of the handbook you feel was violated?
Is there any other information that may help us understand why you feel your rights were violated by your employer?
Can you tell us how you feel you’ve been damaged by the action your employer has taken against you?
Are you a union employee?:
Is the opposing party a union?:
Are you a public employee?:
Was a grievance filed?:
What was the outcome of the grievance?
Were charges filed?:
If charges were filed, where were they filed?:
Have you ever been a party in a lawsuit?: