Consultation

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Name *

First

Last

Age *

Phone Number *

E-mail address *

Name of Employer? *

Nature of employer’s business *

Did you sign an employment agreement prior to commencing employment? *

Yes No

Were you induced to leave another company to join this organization? *

Yes No

What is your job title? *

How long have you been with the Company? What are your duties? *

What are your gross annual earnings *

What reason were you given for the termination? *

Do you believe this reason was valid? *

Are there any disability issues? *

Were you offered a severance package? *

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