ZIP Code or City: *

I am a:

Employee

Former Employee

Job Applicant

Independent Contractor

Employer

I believe I am being discriminated against based on my:

Age. My age is:

Disability. My disability is:

Gender. My gender is:

National origin. My national origin is:

Race. My race is:

Religion. My religion is:

Sexual orientation. My sexual orientation is:

Other:

The discrimination occurred at this stage of the employment:

Hiring

Firing

Layoffs

Compensation

Promotion or transfer

Normal work

What date or time period did the discrimination occur?:

Are there any witnesses and/or evidence to support your claim?:

Yes

If Yes! Explain:

Date of hire:

Occupation / job title:

Is the employee still working for the employer:

Yes

No. Last day of employment was:

Employment has not yet begun

Last day of employment was:

The employer is a:

Sole proprietorship (mom and pop)

Partnership

Franchise

Privately held corporation

Public corporation

Non-profit

Professional organization (law, accounting, architecture, etc.)

Government agency

I don't know

The employer is involved in this type of industry:

High technology

Retail

Professional (law, accounting, architecture, etc.)

Construction

Education

Government

Manufacturing

Transportation

Health Care

Restaurant

The employer has the following number of employees:

1-4

5-50

51-100

101+

What type of employment contract do you have:

At-will employment - either party can terminate

Written contract for a specified period of time

Oral contract for a specified period of time

Union contract

No contract

I am not sure

A complaint was filed with the:

Put upper field date here:

How well do you understand your legal situation or issue? Please select the statement that best applies to your situation:

I understand my legal issue.

I have a couple of questions.

I have a lot of questions.

Gross annual income:

$25,000 or less

$25,001-$50,000

$75,001-$100,000

$100,001-$125,000

$125,000+

One Line Summary of your Case: *

Describe your Case in Detail: *

First Name *

Last Name *

City *

State or Province *

Zip / Postcode *

Phone *

Email *

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Release my contact infoto Lawyers *

Yes

Notify me when lawyers respond by: *

Text Message

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What level of experience would you like your lawyer to have?

No preference

6-15 years experience

1-5 years experience

over 16 years of experience

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I can't pay.

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