Employer Information

Employer Name

Type of Buiness

Address of Employer

City, State, Zip of Employer

Employer's Number of Employees

Position Held

Date of Hire

Are you still Employed

• No
• Yes

Salar or Hourly Wage

Number of Hours typically worked per week

Did you receive overtime for more than 40 hours in a work week?

• No
• Yes

Do you have a written employment contract?

• No
• Yes

Did you make any complaints of discrimination/harassment/retaliation/illegal activity?

• No
• Yes

Case Information (Why do you believe you were treated wrongly?)