Your Name (required) Your Email (required) Telephone City State Employer at issue Job Title What was your approximate annual wage? How were you paid? SalaryBy the hourTipsBonusCommissionOther Did you ever work more than 40 hours in a workweek? YesNo What is your employment issue (check all that might apply)? Not paid minimum wageNot paid overtimeWrong pay deductionsUnfair tip poolDiscriminationRetaliationWrongful dischargeHarassment/Hostile work environmentNot hiredPromoted, demoted, or reassigned unfairlyDenied raise/pay cutRetaliationFailure to accommodate medical conditionUnemployment benefitsMen and women not paid equallyMilitary leave/reinstatementMedical/maternity/paternity leaveOther leave/vacation/PTOGovernment employee rights/Federal employeeSeverance PackageOther If discrimination, what type (check all that might apply)? AgeDisabilityGenderNational OriginPregnancyRaceReligionSexual HarassmentSexual OrientationOther What happened to you? Did you ever complain to anyone (employer, friend, government agency, etc.) about the employer’s conduct? What evidence to you have such as documents, witnesses, emails, etc.? Any other additional information? Please remember to hit send