Potential Labor and Employment Law Client Questionnaire

Fill Out Form for Confidential Review and Free Advice from Leading Los Angeles Employment Law Attorneys

Thank you for contacting our law office for potential representation. To better assist us in analyzing your specific labor and employment law issues, please provide us with the information requested. One of our employment law attorneys will personally review the information you provide. If you have any questions in the meantime, contact a Los Angeles lawyer at our law firm today to set up a free initial consultation.

  • INFORMATION ABOUT YOU
  • Previous Names or Aliases
  • Your Immediate Family
  • Source
  • Prior Lawsuits / Arbitrations
  • Bankruptcies
  • Criminal Convictions
  • Workers' Compensation
  • Prior Employment
  • Public Information About You
  • PARTIES AGAINST WHOM YOU SEEK LEGAL ACTION
  • EVENTS THAT CAUSED YOU TO SEEK LEGAL ACTION
  • OTHER ATTORNEYS YOU HAVE COMMUNICATED WITH
  • COMPLAINTS TO EMPLOYER
  • COMPLAINTS TO UNION
  • COMPLAINTS TO GOVERNMENTAL AGENCIES
  • RETALIATION FOR COMPLAINING
  • Dates of Employment
  • YOUR JOB WITH THIS EMPLOYER
  • Performance Evaluations
  • Termination of Employment
  • General Job Characteristics
    Please select the statement which best describes your job:

  • WAGE & HOUR (MINIMUM WAGE, OVERTIME, MISCLASSIFIED AS EXEMPT, ETC.)
    What were your usual working hours? (Start and end time, for example, 8:00 am. – 6:00 pm). Please state the hours you actually usually worked, not just what you were scheduled for.

  • What were your rates of pay, and when? (Estimates are okay.)
  • (Start - End)
  • (Start - End)

  • For each job title you listed above, please generally describe the duties of that job:

  • If at any time you had any supervisory responsibility with your employer, describe, and when:
  • (Start - End)
  • (Start - End)
  • BREAKS AND MEAL PERIODS
  • EMPLOYMENT-RELATED EXPENSES
  • VACATION PAY
  • DISCRIMINATION & HARASSMENT
  • WITNESSES & EVIDENCE
  • EFFORTS TO SEEK NEW EMPLOYMENT
  • EMOTIONAL DISTRESS
  • PLEASE READ CAREFULLY AND SIGN BELOW
  • I understand that I have provided the foregoing information solely for the purpose of having my case reviewed. I understand that the Law Offices of Kesluk, Silverstein & Jacob, has made no decision whether to take my case, and is under no obligation to do so. I understand that submission of this information does not create an attorney-client relationship, and that if and only if my case is accepted, a written Attorney-Client Fee Agreement will be provided. Please bear in mind that, if you have time deadlines (or statutes of limitations) that are quickly approaching, we cannot guarantee that we will respond in time for us to assist you in filing a lawsuit or administrative agency complaint. You should take immediate action to avoid missing any such deadlines. You may fax your questionnaire to (310) 273-6137. Or, mail it to: Law Offices of Kesluk, Silverstein & Jacob 9255 Sunset Blvd., Ste. 411 Los Angeles, CA 90069 I certify that the information I have provided in this questionnaire and in any attached documents is true to the best of my knowledge and belief.
  • If you have questions about this form, please contact a Los Angeles labor attorney at our law firm to assist you.