17 Academy Street, Suite 1010, Newark, NJ 07102 • (973) 242-3636 • intake@thedwyerlawfirm.com

Questionnaire

Please complete this questionnaire as thoroughly as possible.

If something does not apply, just write "N/A". There may also be instances where you do not know something we ask about on the form. If that is the case, just tell us you do not know.

By providing this questionnaire, we are NOT agreeing to represent you or to be your attorneys. This is a preliminary inquiry to enable us to make a solid evaluation of your facts and a determination of whether we will represent you in the future.

Name	Home address
City	State	Zip Code
Telephone	Cell	Email Address
Date of Birth	Name of Employer
Employer's Address
How long with this employer?	Job Title	Salary
Did you have an employment contract?	Yes No
Were you a member of a union?	Yes No
Does your claim arise out of any of the following (check all that apply):
You were fired, laid off or involuntarily terminated
You were harassed on the job
You were denied a job or refused a promotion or a salary increase
You were denied an accommodation for a handicap/disability
You were treated unfairly in some other fashion. Please briefly specify:

Please give the date when the most recent adverse action was taken against you by the employer:
Do you claim that the treatment you have suffered on the job is related to any of the following (check all that apply):
Retaliation. If so, please specify what you did or said or complained about that you believe resulted in retaliation:

Discrimination. If so, please specify any that apply:
Age
Sex/gender
Race/national origin
Physical or mental handicap/disability
Religion
Sexual Orientation
Marital or family status
Other. Please specify:

Family medical leave
Breach of contract
Even if it is not actually true, please describe the reason(s) the employer would probably give for the actions it took against you:

Even if you cannot prove that it's true, please describe what you believe are the real reasons for the actions the employer took against you:

If you already have any claims pending related to this employer (for example, in court, workers compensation, unemployment compensation, with the EEOC or DCR), please describe those claims and their current status:

How did you learn about our office?