Employment Matter Review

If you are inquiring about an individual employment law matter for yourself, please complete this form as completely as you can. If this is a matter the firm may be able to handle for you, please expect a telephone call or email within 24 business hours.

If you are an employer or are inquiring on behalf of a company, please use the Quick Contact Form.

Your Information:

Name:

Address:

City:

State:

Zip Code:

Personal Email:

Date of Birth:

Phone:

Employer's Information:

Employer's Name:

Which category best describes the employer?:

What is the employer's approximate size?:

What is/was your employment status?:

Are you a member of a union?:

YesNo

Job Information:

Job Address:

Job City:

Job State:

Job Zip Code:

Job Position at Issue:

Annual Salary:

Do you have an employment contract?:

YesNo

Date Hired:

Date of termination or date of last unlawful event:

Did you ever work more than 40 hours in a work week without receiving overtime pay?:

YesNo

Identify any deadlines that are approaching for your legal matter:

Describe your legal concern:

What relief and/or monetary amounts are you seeking?:

Identify any other lawyers you have contacted about this matter:

How did you hear about Searcy Law Firm?:

If you were discriminated against because of a disability please (a) identify your disability, (b) identify any requests by you to your employer for changes or assistance to do your job because of your disability; (c) identify the date(s) on which you made such request(s); and (d) identify your employer’s response to each such request:

If you experienced retaliation for reporting discrimination, workplace safety issues, or for engaging in any other legally protected activity, please briefly describe (a) what you reported; (b) the date(s) on which you reported it; (c) the person(s) to whom you reported it; (d) what retaliation followed; (e) the date(s) of the retaliation; and (f) the person(s) responsible for the retaliation:

If you complained to your employer about your legal concern, identify the date on which you complained and briefly describe the employer’s response to your complaint.:

What, if any, reasons did your employer give for any acts you believe are wrongful?:

If you filed a complaint with the EEOC or other administrative agency, identify the date on which each such complaint was filed and state the status of each such complaint:

Disclaimer: While the firm will keep information that you provide confidential, submission of this form does not form an attorney-client relationship. Such a relationship would exist only upon signing of an engagement letter with the firm, which would occur only after the firm receives additional information about your legal matter and agrees to provide a consultation.

I accept the above terms