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Home Phone

Business Phone

Cellular or Pager

Facsimile

Please provide the name and address of the employer involved: (We require this information to ensure that our firm does not have a conflict of interest)

How many employees work for the employer?

How many employees work for the employer? 1-5

How many employees work for the employer? 5-10

How many employees work for the employer? 11-15

How many employees work for the employer? 15-50

How many employees work for the employer? 50 and above

Are you a current ______ of this employer?

Are you a current ______ of this employer? employee

Are you a current ______ of this employer? former employee

Are you a current ______ of this employer? job applicant

Are you a current ______ of this employer? prospective employee

Are you presently employed?

Are you presently employed? Yes

Are you presently employed? No

If yes, please provide your job title and employer's name and address.

Can you be contacted at work?

Can you be contacted at work? Yes

Can you be contacted at work? No

If you have suffered an adverse employment action (such as termination, demotion, failure to promote, suspension, reduction in hours or reduction in pay), please state the reason given by your employer for the adverse action

If you have suffered an adverse action as described above, please state what you believe to be the reason for the adverse action (such as being in a protected class based on race, sex, national origin, age, disability, religion or engaging in protected activity such as whistleblowing, using medical leave or filing a worker's compensation claim) and identify any evidence you believe supports your claim (such as discriminatory comments or being treated differently than other employees)

If you believe you have been subjected to sexual harassment or subjected to a hostile work environment based upon your being part of a protected class (such as sex, race, age, religion, disability or national origin), please describe in detail the conduct to which you have been subjected, including any relevant dates

Are you a union member?

Are you a union member? Yes

Are you a union member? No

If yes, provide the name, address, and local number

Have you made a complaint about your situation to any governmental agency?

Have you made a complaint about your situation to any governmental agency? Yes

Have you made a complaint about your situation to any governmental agency? No

If yes, provide the name of the agency, the date you made your complaint, and the final result, if any, of your complaint

Are any other people involved?

Are any other people involved? Yes

Are any other people involved? No

If yes, provide names, addresses (if known), and their relationship to you, if any

Do you have any documents that could help explain your situation?

Do you have any documents that could help explain your situation? Yes

Do you have any documents that could help explain your situation? No

If yes, list those documents and their dates:

Are there other documents that you do not have access to that could be of assistance?

Are there other documents that you do not have access to that could be of assistance? Yes

Have other attorneys worked on this matter or were you referred to our office by an attorney? No

If yes, list those documents and their dates and locations (if known)

Describe how this situation has impacted you

Describe what you would like to happen to resolve your issue (your preferred outcome)

Have other attorneys worked on this matter or were you referred to our office by an attorney?

Have other attorneys worked on this matter or were you referred to our office by an attorney? Yes

Have other attorneys worked on this matter or were you referred to our office by an attorney? No

If yes, provide names, addresses, and a brief description of their involvement

Special concerns

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The Law Offices of Dana M. Gallup, P.A. represent employer and employees in employment law matters throughout all of South Florida and Southwest Florida, including the cities of Aventura, Boca Raton, Boynton Beach, Cooper City, Coral Springs, Dania, Delray Beach, Fort Lauderdale, Hallandale, Hialeah, Hollywood, Margate, Miami, Miami Beach, Miami Shores, North Miami, North Miami Beach, Palm Beach, Pembroke Pines, Sunny Isle Beach, Tamarac, West Palm Beach, and Wilton Manors.

Broward County, Collier County, Dade County, Lee County, Miami County, Monroe County, and Palm Beach County.