| Date: |
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| *Name: |
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| *Address: |
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| *City: |
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| *State: |
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| *Zip Code: |
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| *Telephone: |
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| *Your Email Address: |
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Is this email address provided
by your employer: |
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| *Name of Employer: |
Address of employer |
| Number of Employees: |
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| Your Position: |
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| Briefly describe your typical duties: |
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| Were/Are you paid a salary or an hourly rate? |
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| Salary or Hourly Rate: |
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| Length of employment: |
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| If you quit or were terminated, date of quit or termination: |
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Did/Does your employer keep track of your hours worked?
(i.e., time clock, time cards) |
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| If salaried, do you believe you are/were properly classified as an exempt employee? |
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| If not, why? |
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| If salaried, did/do you spend the majority of your time with managerial and administrative duties? |
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| If salaried, did/do you earn at least $2,340.00 per month? |
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| Were/Are you classified as an independent contractor? |
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| Do you believe you should be/should have been classified as an employee? |
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| If so, why? |
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| Did/Do you normally work over 40 hours per week? |
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| If yes, how many hours per week did/do you work on average? |
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| Did/Do you get paid time and one-half for your overtime? |
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| Were/Are you paid at least minimum wage ($6.75/hr. since 1/1/02) for all hours worked? |
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| Were/Are you given paid 10 minute rest breaks for every 4 hours worked? |
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| Were/Are you given unpaid meal breaks of at least 30 minutes for every 5 hours worked? |
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| Are there other current or former employees that are in the same situation? |
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Did/Do you have an
Employment Contract: |
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| Did you sign an arbitration agreement with your employer? |
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| If your complaint is about unpaid wages, what kind of wages do you believe are due? |
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| If you are not now employed, under what circumstances did you leave? |
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| Is your leaving your employment what is motivating you to contact an attorney? |
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| If you were terminated or laid off, what was the reason your employer gave you (even if you do not believe it)? |
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| If you do not believe your employer's reason, what do you think the real reason was? |
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| If there is a reason other than or in addition to your termination, what is the situation that is leading you to contact an attorney? |
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| If your complaint is about sexual harassment, describe the nature of the harassment |
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What is the harasser's position?
(i.e., supervisor, co-worker) |
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| What do you think is causing/caused the sexual harassment? |
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| Did you complain about the sexual harassment? |
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If yes, to whom did you complain?
(Identify by position, i.e., my supervisor) |
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If your complaint is about discrimination,
what type of discrimination?
(check all that apply): |
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| If age discrimination, how old are you? |
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| If your complaint is about sexual harassment or discrimination, have you filed a claim with the DFEH and/or EEOC? |
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| What do you want Pope, Berger & Williams, LLP to do for you? |
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| Please provide any additional information you believe would be important for the attorneys to know: |
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