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Empl.LawForm

BESTLAWYER^� Legal Services Inquiry Request Form

Select the items that apply, and then let us know about your legal problem and how to contact you.

Discrimination
Sexual Harassment
Family Medical Leave Violations
Retaliation
Other (Specify Below)

WELCOME

The details of your situation are very important. With the information you provide, we will be able to represent you more effectively. Please complete this form as accurately and quickly as possible. If you have any questions, please ask. We will be happy to help you.

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While the form is currently under construction, you may still use it; If you prefer or have any problems completing the form, call us at (310) 277-3000 or fax us at (310) 855-3380 with your answers to these questions

1. ABOUT YOU

Your Legal Name*
What You Prefer To Be Called
Your Birthdate
Prospective Client's Age*
Social Security Number (Enter Without Spaces or Hyphens; If You Have No Social Security Number, Enter 000000000)*
Your Driver's License Number
Your Place of Birth
Your Sex	Female Male
Your Marital Status*
Your Spouse's Name
Your Sexual Orientation (If Applies to Your Case)
Personal Contact's Name, Relation to You, Address and Phone Number (In Case We Can't Reach You)
Potential Client's Race and/or Ethnicity (Check ALL that apply)	Black/African-American Asian Hispanic White/Caucasian Mexican-American American Indian Filipino/Philipino Other:
Discriminatory Treatment and Date of Discrimination (Check ALL that apply AND list dates for each)	Terminated on Laid Off on Not Hired on Denied Promotion on Harassed on Retaliated Against on Denied Disability Leave on Denied Pregnancy Leave on Denied Family Care Leave on Denied Disability Accommodation on Denied Other Accommodation on Denied Equal Pay on Other: on
Your Address
E-mail*	@.
Home or Primary Phone*	() -
Work Phone	() -
Cell Phone	() -
Fax Phone	() -
Where Do You Prefer We Call	Home Work Cell
Best Time to Reach You
Termination Date (If Applicable)
Most Recent Date of Discrimination/Harassment*
Question	Yes No
Referred by (e.g., Co-worker, Friend, Relative, Ad, Internet, Other):
Name & Address of person that referred you:
Number of felony convictions?
Current Employer:
Employer's Address:
Job Title:
Employed since:
Supervisor's Name:
Have you seen any other attorney(s) regarding this case?	Yes No
If yes, whom?
2. COMPLAINT I Wish To Complain Against: (Name and address of company, government entity, employment agency, union, etc.) Name: Address: Telephone #: Number of employees (estimate): Job site Company wide I Wish To Complain Against: (other named individuals who were involved in this particular complaint.) Name Title Telephone #: Address (if known): I believe I was discriminated against because of: Race Sex Sexual Orientation Marital Status Color Pregnancy Religion Ancestry Medical Condition Age (40 and over) National Origin Disability (including AIDS) Denial of Family Care Leave Why do you believe the unfair treatment was discrimination? (If others were treated better than you, give names, addresses and examples.) List the names, addresses, job titles and telephone numbers (if possible) of witnesses, co-workers, or others you feel could provide evidence. Explain what you think each witness will be able to tell us. Employment Data: (complete as many items as you can) A. Date hired or applied for job: B. Job title/salary at time of discrimination: C. Name and title of immediate supervisor or interviewer: D. If your employment was terminated, who replaced you? E. If your employment was terminated or if you were refused a job, have you since been employed? Yes No If yes: Date of hire: / / Salary: Job Title: F. If not hired: • How did you know about the job and/or salary? • Did you apply by written application or verbally? • To whom did you submit the application (and date)? • How did you find out you had been refused (and date)? • Who got the job, salary, etc. (if known)? Have you filed a complaint with the U.S. Equal Employment Opportunity Commission (EEOC) or the Department of Fair Employment and Housing (DFEH) before coming here: Yes No Date: / / EEOC DFEH Charge/Complaint Number: Have you talked to another attorney concerning this problem Yes No If yes: Name: Telephone #: Address: Complainant's assertions: What does Complainant say the employer's position will be? Comparative data/relevant information (i.e., how have they treated others): What does Complainant want as a remedy (i.e., what would satisfy you if provided to you by your employer/prospective employer) ? 3. ABOUT YOUR LOSSES How much time have you missed from work? Rate of pay: $ Per: Have you lost the ability to do your job as before? Yes No Have you lost any ability to perform any tasks? Yes No Have you gone to a doctor or hospital regarding this matter? Yes No Do you require medical services? Yes No Do you require psychological services? Yes No Doctor/Psychologist/Psychiatrist's Names, Addresses and Phone Numbers: Have you made a workers compensation claim regarding this matter? Yes No If so, who is your workers compensation attorney (including phone number)? If so, has your current claim for workers compensation benefits been: Accepted Denied Don't Know Consider all termination/discrimination/harassment related expenses and estimate your total monetary loss: $ 4. DISABILITY DISCRIMINATION SUPPLEMENT (Only Answer If a Disability Discrimination Case) What is your disability? When did you first learn you had this disability? Has a physician diagnosed you as having this condition or disability? Yes No If yes, please provide the name and phone number of the physician and the most recent date of diagnosis: When did the employer/company first lean of your disability? What is the name and job title of the supervisory or management employee who first learned of the disability? What action was taken against you by the employer (e.g., denied hire, terminated, denied an accommodation, etc.)? What is the name and job title of the person who made the decision to take this action against you or deny you an accommodation? What reason did the employer give you for the action taken against you? What is the name and job title of the person who gave you this reason? What is the job title and pay of the position in question? What are the essential or primary duties of this job?
Are you able to perform the primary duties of the job in question?	Yes No
Has your physician placed any medical restrictions on your performing the job in question? Yes No If yes, answer the following: Name and phone number of physician who placed the restrictions: Date the restrictions were imposed: Describe the restrictions: Do you need an accommodation to enable you to perform the primary duties of the job in question? Yes No If yes, what is the accommodation? Have you asked the employer to accommodate your disability? Yes No If yes, did the employer grant the accommodation? Yes No If the employer did not grant the accommodation, what reasons were you given for the denial and what is the name and job title of the person who gave you this reason? Do you think the employer could have accommodated you? Yes No If yes, why do you believe this? Has the employer required you to take a physical or mental examination? Yes No If yes, please provide the following information: Name and phone number of examining physician: Date of examination: Describe any restrictions placed on you by the examining physician:
Legal Problem/The Reason for Your Inquiry

After completing the above, and reading our Terms of Use and Disclaimer Agreement, and after reading the Important Note, below, CLICK the "Understood and Agreed" Button below to submit your Legal Service Inquiry Request Form and indicating your agreement to and understanding of the Terms of Use and Disclaimer Agreement and of the Important Note, below. THE ABOVE IS TRUE AND CORRECT TO THE BEST OF MY MEMORY AND BELIEF AND CLICK BELOW TO INDICATE SAME:

IMPORTANT NOTE: Please note that using this Request Form does NOT create or form an attorney-client relationship with us. Only the signing of an Attorney-Client Retainer Agreement by both you the potential client AND our office will create an attorney-client relationship. Notwithstanding this, information provided on this form may be considered attorney-client privileged and confidential. Further, please note that email sent to us from your place of employment may be subject to monitoring by your employer; we therefore strongly recommend that you email us only from home. If you need immediate attention, please call us at (310) 277-3000 or fax a note to us at (310) 855-3380.

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Last modified: Saturday, May 30, 2009.

BESTLAWYER� Legal Services Inquiry Request Form

BESTLAWYER^� Legal Services Inquiry Request Form