Employee Information
Employer Information
What type of unpaid wages? Regular HoursOvertime HoursUnpaid Vacation
What type of Wrongful Action are you claiming?: TerminationFailure to PromoteDemotionFailure to HireHarassmentUnsafe work conditionsFailure to Pay WagesFailure to provide meal breaks or rest breaksOther
REASONS FOR WRONGFUL CONDUCT
DISCRIMINATION
Do you believe that the employer's wrongful action was the result of discrimination based on one of the following? (Please check if applicable) SexRaceDisability PregnancyWas the employer aware of the pregnancy?Sexual HarassmentAgeRetaliationWhistle Blowing (i.e., complaining about illegal conduct by your employer or refusing to do something illegal)Sexual OrientationOther (describe) If you feel you have been discriminated against based on one of the above, please give specific examples that show that the unfair treatment is caused by the discrimination (such as, discriminatory remarks, different or unfair treatment, under-representation, etc.) Please state if any witnesses to the discrimination and briefly describe what they might testify to:
JOB PERFORMANCE
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