New Client QuestionnairePlease complete all fields. If you have any questions, please reach out to your attorney directly. Name * First Name Last Name Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Has any other attorney represented you in this matter? If so, who? * Social Security Number Personal History Have you ever used, or been known by, any other name? If so, what other names and when? State the addresses where you have resided during the past 10 years, and the period of time at each residence, including dates: Name of spouse and date married: Names and ages of any dependents you have: Employment History Name and Address of Most Recent Employer: Start Date MM DD YYYY End Date MM DD YYYY Job Title Name and Title of Supervisor Beginning Pay Rate End Pay Rate Were you paid commissions or bonuses? If so, explain: Do you have a copy of your employment agreement? Are you or have you been a member of a collective bargaining agreement or union? Did you make any internal complaints at work? If so, to who and what was the nature of your complaint? Have you ever been disciplined at work? If so, explain: While prior disciplinary action may not be relevant to your claim, it is important that we are aware of past events. Have you ever been fired from a job? If so, explain: If you believe you were treated unfairly, are there any other employees you believe were in the same situation but treated differently; any others treated the same as you? If so, please provide all identifying information available, including age, race, sex, sexual orientation (if known), and any known disability In you own words, briefly state the reason(s) you are seeking legal help? Are there any witnesses to the conduct you are complaining about? If so, please provide their names and any contact information you have available Educational Background What education have you had, including any special job training? What degrees do you hold and from what schools? Military Background Have you served in the military? If so, name branch? Type of Discharge Do you have any service-connected injuries or disabilities? If so, give details: Prior Claims and Lawsuits Many cases have been damaged beyond repair by a history of other claims and/or lawsuits which your attorney did not know about. It is NOT the fact that one has had other claims or lawsuits that is important, for one will not be penalized by a court or jury if the claims are reasonable and genuine. It is the DENIAL of previous claims and suits that damages the case. List every claim you have ever made for discrimination, personal injury or property damage, and give details: Police Record Under the rules of evidence, there are circumstances under which a person's prior criminal record may be relevant in a proceeding. The other attorney will make a complete investigation of your background, and we must be PREPARED AGAINST development of unfavorable evidence. List here any arrest(s) and state the date, place, charge, court, case number and outcome: Workers’ Compensation Have you ever made a claim for Workers’ Compensation? If so, when was the date of your injury? MM DD YYYY Who is handling your Workers’ Compensation action? Miscellaneous Is there any other information you would like me to know? Thank you for your submission.
