Employment Law Information Online Form TAF Employment Law Form Thank you for allowing The Allen Firm, PC to help you. Our Firm values people and developing personal relationships. In order to make sure your information is updated and current, please complete the following information. Please complete the following area with your detailed contact information.Today's Date* MM slash DD slash YYYY Personal InformationName:* First Last Address:* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Address:* Primary Contact Number:*Date of Birth:* MM slash DD slash YYYY Drivers License Number and State:* Last 4 Digits of SS #:* Professional Degrees, Licenses, Certifications:Spouse InformationName: First Last Date of Birth: MM slash DD slash YYYY Last 4 Digits of SS #: Drivers License Number and State: Primary Contact Number:Email Address: This ConsultationThis consultation is regarding my: Current Employer Previous Employer Current Employer InformationEmployer: Date of Hire: MM slash DD slash YYYY Job Title: Please explain your job duties:Work Contact Number: Work Email: Employer Address:Type of Company: Number of Employees: Number of Employees in your Office: Length of Employment: Status of EmploymentPart-TimeFull-TimeTemporaryProbationaryContract EmployeeSelf-employedPlease explain your work schedule:Please list days and times.Gross Annual Salary: Other Income:Please enter any other income from this employer. (Commissions, bonuses, expense reimbursement)Please check all that apply to you. I set my own schedule, days, times to work I bring and/or use my own tools/equipment I determine how the job will be performed, not my employer Previous Employer InformationEmployer: Address of location where you worked:Type of Company: Address of Corporate Headquarters:Number of Employees in Company: Number of Employees in your office: Date of Hire InformationDate of Hire: MM slash DD slash YYYY Job Title at date of hire: Job Duties at date of hire:Status of employment at date of hire:Part-TimeFull-TimeTemporaryProbationaryContract EmployeeSelf-employedAt date of hire you were paid: Hourly Salary Commissions Bonuses Overtime Expense Reimbursement Please check all that apply.At date of hire your rate of pay: Termination InformationJob Title at Termination: At Termination you were paid: Hourly Salary Commissions Bonuses Overtime Expense Reimbursement Please check all that apply.At termination your rate of pay: Status of employment at termination:Part-TimeFull-TimeTemporaryProbationaryContract EmployeeSelf-employedJob Duties at termination:Why do you Need Legal Services?Legal Service Choices What unemployment benefits Want unpaid overtime or bonuses I feel I may have been wrongfully terminated (i.e., Illegal discrimination, retailation, etc.) Need review of severance package, release, or non-compete agreement Other Check all that apply.Adverse Employment ActionCheck all that apply: Termination Resignation Demotion Pay Cut Harassment Other Date the above took place: MM slash DD slash YYYY Your status of employment at the time:Part-TimeFull-TimeTemporaryProbationaryContract EmployeeSelf-employedName of Supervisor: First Last Disciplinary actions leading up to this action:Were the disciplinary actions taken according to company policy?NoYesReason given by company for this action:Reason you believe action was taken:Did you appeal the decision within the company?YesNoOutcome:Unemployment BenefitsAre you receiving unemployment benefits?YesNoIf no, have you filed for unemployment benefits?NoYesDate of Filing: MM slash DD slash YYYY Determination:ApprovedDeniedDecision PendingHave you filed for an appeal?NoYesDate of Appeal MM slash DD slash YYYY Outcome of appeal:Do you currently have a TWC hearing scheduled?NoYesDate of Hearing: MM slash DD slash YYYY Wrongful Termination(If applicable)Check any of the following that you believe might apply: Harassment Retaliation Discrimination based on race Discrimination based on national origin Discrimination based on age Discrimination based on disability Discrimination based on gender Please explain:How many instances of above behavior occurred? Please list those involved in this behavior:Did you report this behavior?NoYesHow did you report this?VerballyIn writingTo whom and on what dates:Outcome:Formal Complaints(If applicable)Have you filed an EEOC complaint in this matter?NoYesDate Filed: MM slash DD slash YYYY Was a determination letter issued?NoYesDate letter was received: MM slash DD slash YYYY What was the determination?Are you aware of any pending deadlines in this case?NoYesHave you filed a complaint within the company or an appeal?NoYesDate Filed: MM slash DD slash YYYY Outcome:Potential WitnessesPlease list any and all possible witnesses:Use of AttorneyWhat do you hope to accomplish through an attorney?(i.e., get job back, etc.) Previous legal actionHave you consulted with another attorney in this matter?NoYesOutcome:Have you ever filed suit against a former employer?NoYesHow many times? Outcomes:Please list dates and outcomes.Employment HistoryHow many jobs have you had in the last ten (10) years? AcknowledgementI have answered the questions above honestly and completely, to the best of my knowledge. Digital Signature* First Last