Name:*

Email:*

Phone:*

Name of employer or former employer:

How long did you work/have you worked for the company?

What was your job title and salary?

If you are complaining about a wrongful termination, what reason did your employer give for terminating you?

What do you think is the real reason you were terminated?

If you are complaining about harassment or discrimination, please provide pertinent details.

Additional comments:

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