Name:

Address (include city, state, and zip):

Telephone:

 - Home

 - Work

 - Cell

Email address:

Confirm email:

Date of birth:

Place of birth:

Gender:

-- Select -- Male Female

Race:

-- Select -- Caucasian/White African-American/Black Hispanic Asian Other

US Citizen:

-- Select -- Yes No

Employer about whom you are contacting us.

Address of employer:

Does your employer gross over $500,000 a year?

-- Select -- Yes No

Rate of pay:

  per  -- Select One -- Hour Week Month Year

Hire Date:

Last position held:

Are you still employed with this employer?

-- Select -- Yes No

If no, why did you leave?

Are there any written documents outlining the terms of your employment?

-- Select -- Yes No

Did you have a written contract?

-- Select -- Yes No

Are you required to arbitrate employment disputes?

-- Select -- Yes No

If yes, have you requested arbitration of this matter?

-- Select -- Yes No

Do any of the documents provided or maintained by your employer contain an overtime policy?

-- Select -- Yes No

What is that overtime policy?

Did that policy require you to obtain approval before working overtime?

-- Select -- Yes No

If you were required to request approval, did you do so?

-- Select -- Yes No

Why or why not?

How many hours a week did you work, on average?  (Please include all breaks which were required to be taken on site, any pre or post work preparation or follow-up, and any time which you were required to travel between the employer?s facilities or locations.)

What was the method of reporting hours?

-- Select -- Time Clock Time Sheets Other

If other, please explain.

Did you ever have to stay before or after work to complete any tasks that were directed by your supervisor(s) or which were required to do your jobs?

-- Select -- Yes No

If yes, then how do you know that your supervisor(s) knew of the amount of work you were performing?

How often did you have to perform these tasks?

How many hours per day or week did you perform these tasks?

Over the past two years, how often did this take place?

Did anyone ever tell you that you had to work hours greater than 40 a week?

-- Select -- Yes No

Who communicated to you that you had to work additional hours?

How many compensated hours did you receive for the following?

Did you ever receive payment for bonuses?

-- Select -- Yes No

How much pay did you receive over the past two years?

How much pay did you receive over the past three years?

Did you ever receive other compensation of any other type from your employer that was not for hours worked?

-- Select -- Yes No

If so, what type?

How much of such pay did you receive over the past two years?

How much of such pay did you receive over the past three years?

What were you told regarding your employer?s policy about paying overtime?

Who told you this information?

What was this person?s position with the employer?

Did you ever receive any type of overtime payment?

-- Select -- Yes No

If so, how much and when?

Were you ever told you were on a salary?

-- Select -- Yes No

If yes, what were the terms of the salary arrangement?

Did you supervise any employers?

-- Select -- Yes No

If so, how many?

What were your job responsibilities in your position?

Where you responsible for any management-type functions?

-- Select -- Yes No

If yes, what percentage of your job was related to such functions?

What were the functions that you would consider to be managerial?

Did your position require a professional degree or artistic skills?

-- Select -- Yes No

If yes, please explain.

What were you told regarding why you were paid on a salary basis?

Why do you believe that you were on salary status?

Did you obtain any commissions for your work?

-- Select -- Yes No

Were you employed by either a retail or service establishment?

-- Select -- Yes No

Were commissions more than 50% of your weekly compensation.

-- Select -- Yes No

Were you ever provided any compensatory time options (an offer to take additional off rather than receive overtime pay)?

-- Select -- Yes No

Check any of the following which applied to your position.

If you checked any of the boxes above, please explain further how your position fit any of these categories, or why you are unsure whether you fit any of these categories.

Have other employees also been denied overtime?

-- Select -- Yes No

Approximately how many?

Are any willing to participate in this litigation with you?

-- Select -- Yes No

List name(s), phone number(s) and whether each is a current employee.

Do you have any documents, notes or calendars detailing the number of hours you worked?

-- Select -- Yes No

If so, please describe.

How did you hear of our firm?

-- Select -- Attorney Yellow Pages Newspaper Article Web Search Other

If an attorney referred you, what is the name of the attorney or firm?

If another person referred you, what is that person?s name?

Have you ever previously formally charged any employer with violation of employment law (for example, violations of overtime laws, OSHA regulations, or EEOC violations)?

-- Select -- Yes No

If yes, please describe.

Have you ever sued anyone before for any reason?

-- Select -- Yes No

If yes, please explain the nature of the lawsuit and the result.

Additional Information

Please provide any additional information about yourself or the case which would help the attorneys understand your potential case or explain your answers to the above questions.

Scheduling

We will contact you by email unless this is not possible.  If you cannot communication via email, please indicate the most convenient method of communication and the best time and day to contact you.

PLEASE READ THE FOLLOWING STATEMENTS AND INDICATE YOUR ACCEPTANCE OF THESE TERMS PRIOR
TO SUBMITTING THIS FORM.

I have prepared the answers to these questions and to the best of my ability.

THIS MUST BE ANSWERED OR YOU CANNOT SUBMIT THE FORM!

I understand that the submission of this form does not create any obligation for me or for any attorney at Delegal Law Offices. 
I further understand that submission of this form does not create an attorney-client relationship and that the lawyer is not obliged
to schedule a consultation with me.

I understand and agree that Delegal Law Offices, P.A., will have no duty to keep confidential the information that I am transmitting to the law firm through this questionnaire.


THIS MUST BE ANSWERED OR YOU CANNOT SUBMIT THE FORM!