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1180 West Peachtree Street
Suite 1100
Atlanta, Georgia 30309

Toll Free: (877) 562-5878
Local: (404) 781-1100
Fax: (404) 781-1101

Please provide us with the information of your case by filling out the Employment Claim Questionnaire below:

Contact Information: Your Name:* Street Address: City: State: Zip code: Home Phone:* Work Phone: Cell Phone: Email:* May we call you at work? Yes No How did you hear about us? Is there a particular attorney at our firm you wish to contact? Name of the company or organization with which you have a dispute: When did you first start working for this organization? Job title: Your rate of pay: Does your inquiry concern any of the following? Briefly describe the dispute problem: Is there a particular date on which you first learned that your employer had decided to take adverse action against you? Do you think that you might have been discriminated against because of any of the following? If you checked 'age', what is your date of birth? Have you filed a charge of discrimination with the Equal Employment Opportunity Commission? If so, when? Have you received a 'Right To Sue Letter' from the EEOC (or a state fair employment agency)? If so, when? Is there any other information that may help us understand your problem?

Please do not include any confidential or sensitive information in this form. This form sends information by non-encrypted e-mail which is not secure.

Submitting this form does not create an attorney-client relationship.

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