Complete the form below to email us:
Notice: The information contained in this form is confidential and will be used by us to assist in determining whether we can help you with your case. No attorney-client relationship is established by the provision of confidential information, and no attorney-client relationship will be established until such time as you and we sign a written agreement establishing an attorney-client relationship. It is understood that we will rely on the fact that the information contained in t his form is truthful, accurate and complete unless noted otherwise.
Name *
Email *
Address *
Phone number *
Name of your Employer *
Total number of employees *
Date you were hired
 *
Your Job Title or Position *
Your annual income or hourly rate
The reason(s) you are contacting Resilient Employment Law *
Required
First date of discrimination / retaliation / harassment while employed by this employer *
MM
/
DD
/
YYYY
Last (most recent) date of discrimination / retaliation / harassment while employed by this employer *
MM
/
DD
/
YYYY
Are you still employed by this employer? *
If you suffered an adverse employment action (such as written discipline, termination, demotion, failure to promote, suspension, reduction in hours or reduction in pay), please state the reason given by your employer for the adverse action. *
Please state what you believe to be the actual reason for the adverse action (such as race, sex, national origin, age, disability, religion, sexual orientation or engaging in protected activity such as whistle-blowing, using medical leave or filing a worker's compensation claim) and briefly describe any evidence you believe supports your claim (such as discriminatory comments or being treated differently than other employees). *
If you believe you were subjected to sexual harassment or subjected to a hostile work environment based upon your being part of a protected class (such as sex, race, age, religion, disability, sexual orientation or national origin), please briefly describe the conduct to which you were subjected, including any relevant dates. *
Have you filed a complaint with the EEOC or the Arizona Civil Rights Division on this matter? *
Does your employment agreement or employee manual state that you are required to arbitrate claims against your employer? *
By checking this box, I understand that the answers I give in this application will be relied upon by Resilient Employment Law to assess my case for legal representation, and the scope of that representation.  I agree Resilient Employment Law is not my attorney and is not taking legal action, or any actions to protect my interests, unless and until a Representation Agreement is signed by both me and the firm. *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Resilient Employment Law.

Does this form look suspicious? Report

Google Forms