*Name:

Address:

City:

State, Zip:

Phone Number:

Fax Number:

*E-mail Address:

DOB:

SS#:

Marital Status:

Kids:

How Many Kids:

Education:

Military:

Employer:

Job Title:

Date Hired/By Whom:

Pay:

Contract/Union:

Employment Manual:

Personnel File:

Supervisor:

Wrongful Actor/Title:

Date of Incident:

Place/Time:

Facts:

Reason Given For Discharge/
What Do You Think Reason Is?:

Witnesses:

Complaint to Management/
Actual or Constructive Knowledge of Employer/
Written or Recorded Statements to Anyone?:

Performance History/
Prior Problems/Reprimands/Reviews?:

Injuries:

Treatment:

Psychological History:

Employment/Lost Wages/Mitigation:

Medical Insurance/Disability:

Advise: Keep Journal/
Two Written Statements-Facts & Damages:

Motor Vehicle/Criminal Record: