* Referred by

* Name

Address

* Phone

* Email address

Preferred mode of communication?

Date and time of incident(s)

Location Where Any Incidents Occurred (City, State, etc.)?

Are there any witnesses?

If so, do you have their contact information?

Number of employees employed by this employer

Did you complain about the incident(s)

If so, to whom, and when?

Have you filed a formal complaint with the DFEH or the EEOC?

If so, when?

Describe what happened and any facts that you think may support a legal claim against the employer

Details of your situation

What is/was your job title at the company?

What is/was your pay rate?

Please tell us anything else you think we should know about your case to better evaluate it