Severance Agreements - Questionnaire

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

US Citizen?

-- Select -- Yes No

Employer about whom you are contacting us.

Address of employer:

Rate of Pay

  per  -- Select One -- Hour Week Month Year

Hire date

General description of the terms of the severance agreement

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?

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!