Personal Contact Information

Name

Address

Phone xxx-xxx-xxxx

Fax

E-mail

Referred by

Employment Information

Age

Employer

Position

Date of hiring

Date of employment termination( if applicable)

Address of employer

Employee Status

Contract Status

Employment Terms

Remuneration type

Other Remuneration (bonus, commission, stock options, etc.)

Benefits (disability, life insurance, extended health, etc.)

Pension

Case Specific Information

Please tell us how we can help you. If you have recently been terminated and are seeking advice about your rights, please include details of your termination, including the circumstances leading up to it, the reasons for it given to you by your employer, and whether you have found new employment:

What else should we know to help you find the best solution to your problem?