Contact Form

Office
Philip S. Marstiller, P.C.
The Marstiller Law Firm

NOTICE: The information contained in this questionnaire is CONFIDENTIAL and will be used by the Marstiller Law Firm, P.C. to assist in determining whether the firm can help you with your case. No attorney-client relationship is established by the provision of confidential information, and no attorney-client relationship will be established until such time as you and we sign a written agreement establishing an attorney-client relationship. It is understood that the Marstiller Law Firm, P.C. will rely on the fact that the information contained herein is truthful, accurate and complete unless noted otherwise.

1. INFORMATION
Date:  
First Name:  
Middle Name:  
Last Name:  
Address-Street:  
County:  
City:  
State:  
Zip:  
Home Email Address:  
Date of Birth:  
Gender:    Male   Female
Ethnicity:  
Home Telephone Number:  
Office Telephone Number:  
Cell Telephone Number:  
I prefer to be contacted by phone:
 At home   At work   By cell phone
Best time to call:  
To which attorney in our office were you referred
(if any)? 		 
How were you referred to/or learned of our office?  
   
 
2. WHO IS YOUR COMPLAINT AGAINST?
Name:  
Address-Street:  
County:  
City:  
State:  
Zip:  
Telephone:  
Type of Business:  
Location(s) elsewhere:  Yes   No
Address:  
Company size/number of employees:
 Less than 15
 15 to 50
 51 to 100		  101 to 200
 201 to 500
 500 or more
   
What Part Do You Take in This Business or Organization?
Date Hired :  
Date of demotion / termination (if applicable):  
Department/Division you work(ed) in:  
Your position:  
Your salary:  
Benefits:  
Your immediate supervisor's name:  
Your immediate supervisor position's title:  
   
DO YOU HAVE AN EMPLOYMENT AGREEMENT, STOCK OPTION, COVENANT NOT TO COMPETE, NON-SOLICITATION AGREEMENT, or ANY OTHER AGREEMENT or CONTRACT WITH YOUR EMPLOYER?
   Yes   No
   
5. HAVE YOU SIGNED ANY SEVERANCE AGREEMENT or SEPARATION PACKAGE WITH YOUR EMPLOYER?
   Yes   No
   
6. HAVE YOU BEEN PRESENTED WITH ANY TYPE of SEVERANCE / SEPARATION AGREEMENT or PACKAGE BUT HAVE NOT YET SIGNED?
   Yes   No
   
7.DO YOU BELIEVE YOU WERE DISCRIMINATED AGAINST/TREATED UNFAIRLY BASED ON: (Check all that apply)
  Sexual Harassment
  Ethnicity
  Appearance
  Sex
  National Origin
  Age
  Religion
  Disability		   Marital Status
  Sexual Orientation
  Retaliation
  Family Medical Leave Act
  Equal Pay Act
  Because I brought to the attention of my employer illegal acts
  Because I refused to engage in illegal acts
  Other (Please Explain)  
   
8. EXPLAIN WHAT ACTION WAS TAKEN AGAINST YOU THAT YOU BELIEVE WAS DISCRIMINATORY OR UNLAWFUL:
   
9. WHY DO YOU BELIEVE WHAT HAPPENED IS DISCRIMINATION, RETALIATION, OR OTHERWISE, ILLEGAL ?
(As you marked in #7)
   
10. WHAT REASON(S), IF ANY, WAS GIVEN FOR THE ACTION TAKEN AGAINST YOU ?
(Tell us who, what, when, where and why.)
   
11. WHAT IS THE EMPLOYER'S NORMAL POLICY/PRACTICE IN A SITUATION SUCH AS YOURS, IF APPLICABLE?
Is the policy in writing:    Yes   No
If yes, can you provide us with a copy?    Yes   No (explain)
 
12. HAS THE SAME THING HAPPENED TO OTHERS ? (If yes, please tell us who, what, when, where and why.)
   Yes   No  
 
   
13. HAVE OTHERS BEEN TREATED DIFFERENTLY THAN YOU FOR THE SAME CONDUCT ?
(If yes, please tell us who, what, when, where and why.)
   Yes   No  
 
   
14. DID YOU REPORT THE ACTION TO ANYONE AND, IF SO, TO WHOM AND WHEN. PLEASE ALSO DESCRIBE WHAT INVESTIGATION, IF ANY, AND WHAT ACTION, IF ANY, WAS TAKEN AS A RESULT OF YOUR COMPLAINT .
 
   
15. DOES YOUR EMPLOYER HAVE A GRIEVANCE/COMPLAINT POLICY/PROCEDURE THAT MAY APPLY?
IF SO, PLEASE DESCRIBE.
 
16. IF THERE IS A GRIEVANCE/COMPLAINT PROCEDURE OR POLICY, DID YOU FOLLOW IT? PLEASE DESCRIBE WHAT YOU DID. IF NOT, PLEASE EXPLAIN FULLY WHY YOU DID NOT FOLLOW IT.
 Yes   No
 
   
17. HOW, IF AT ALL, DID YOUR WORK ENVIRONMENT OR TERMS OF EMPLOYMENT CHANGE FOLLOWING YOUR COMPLAINT ?
 
   
18. IS THERE A KNOWN DEADLINE THAT YOU ARE FACING? (Explain):
 
   
19. DO YOU HAVE ANY WITNESSES ?
(We will not contact anyone until we have spoken to you and obtained your consent.)
Witness 1 /Name:  
Witness 1 / Relevant
Relationship:		  
Witness 1 / Telephone
No - Email Address:		  
Witness 2 /Name:  
Witness 2 / Relevant
Relationship:		  
Witness 2 / Telephone
No - Email Address:		  
Witness 3 /Name:  
Witness 3 / Relevant
Relationship:		  
Witness 3 / Telephone
No - Email Address:		  
   
20. IF YOU WERE TERMINATED, HAVE YOU BECOME RE-EMPLOYED? IF SO, HOW MUCH MORE OR LESS ARE YOU EARNING TODAY IN RELATIONSHIP TO WHAT YOU EARNED AT THE POINT OF TERMINATION ? Please include a detailed and itemized comparison of salary, commissions, bonuses, and all benefits between your previous position (that from which you were terminated, etc.) and your new position.
   
21. HOW DID THESE EVENTS IMPACT YOU, AND DO THEY CONTINUE TO AFFECT YOU TODAY ?
   
22. HAVE YOU EVER FILED ANY TYPE OF DISCRIMINATION SEXUAL HARASSMENT, RETAILIATION, OR WRONGFUL TERMINATION CLAIM OR COMPLAINT BEFORE?
(IF SO, PLEASE PROVIDE A DETAILED DESCRIPTION OF EACH CLAIM AND HOW IT WAS RESOLVED).
   
23. IS THERE ANYTHING ELSE YOU BELIEVE MAY BE RELEVANT, POSITIVE OR NEGATIVE, THAT YOU BELIEVE WE SHOULD KNOW IN CONSIDERING OR EVALUATING YOUR CLAIM, OR IN REPRESENTING YOU?


Please click on the 'Submit' button below to submit the form.