Seeking Representation

We ask people who are seeking representation to fill out a questionnaire and submit it to our office. This helps us to evaluate your case and assess whether we can assist you. You are welcome to submit the online form below or fill out the PDF form and e-mail it or fax it back to our office. You can also call our office to let us know you have sent in a questionnaire or if you have other questions.

Seeking Representation (31K PDF)

Information about you

Date:

Name:

Address:

City:

State:

ZIP Code:

Home telephone:

Work telephone:

Email:

Is it OK to call at work? -- Select one -- No Yes

Social security number:

Referred by:

If you have any deadlines or statues of limitation coming up, please describe:

Please note: We are not responsible for deadlines during the time we are reviewing your case. If deadlines become due, you are responsible for them unless we take your case.

Information about your employment

Employer:

Employer address:

City:

Phone:

Date you began:

Position title:

Time in position:

Total time with employer:

Salary:

Date of last promotion:

Supervisor / title:

Have you filed a complaint with your employer? If so, what happened?

Describe personnel policies or handbooks if there are any:

Describe any performance evaluations you have received:

Information about your union (if any)

Is there a union? -- Select one -- No Yes

Name of union:

Name of union representative:

Have you filed a grievance? -- Select one -- No Yes

If so, what happened?

Information about what happened to you

If some action was taken against you (such as termination, suspension, different treatment, demotion, transfer, etc), describe what happened:

What reasons were given for this action?

Do you believe you have been discriminated against? If so, describe the reason(s) you believe your employer discriminated against you.

If your case involves harassment, please describe:

Please include any other relevant information you have:

Information about outside agencies

Have you filed a complaint with the EEOC? / Date:

Have you filed a complaint with the DFEH? / Date?

Have you filed a complaint with any other agency (e.g. Labor Commissioner, Office of Federal Contract Compliance, etc.)? Name of agency and date filed:

Describe what the agency has done:

Have you received a right-to-sue letter? / Date:

Where you injured on the job?

Name of workers-compensation attorney:

Have you requested reasonable accommodation? / Describe:

Have you been released to return to work? / Date:

Has your doctor put you under any restrictions? / Describe:

Information about legal services

Please describe the legal services you would like our office to provide:

What resolution do you want

Please describe what resolution you would like to see in your case:

If anything is entered here, your submission will be ignored: