PART I.  PERSONAL INFORMATION

Name:             ________________________________________

Address:          ________________________________________

                      ________________________________________

Telephone:       ________________________________________

Age:                ________________________________________

Sex:                 ________________________________________

Race:               ________________________________________

List all current or past disabilities or health conditions (including any mental illness):

#1)       _____________________________              #2)       _________________________________

#3)       _____________________________              #4)       _________________________________

Children?  If so list each:        Name                                                 Sex                  Age                                        

____________________________________________________              ___                  ___

____________________________________________________              ___                  ___

____________________________________________________              ___                  ___

____________________________________________________              ___                  ___

Have you ever filed for workers’ compensation?  If so, please provide the date and nature of claim.

 Have you ever been arrested?  If so, please provide the following information:

Approximate Date      Charges           Resolution                   Brief Explanation

Have you ever been involved in a lawsuit?  If so, please explain each case:

PART II.  EMPLOYER INFORMATION REGARDING YOUR EMPLOYMENT

Name:  _____________________________________________________________

Address:  ___________________________________________________________

                ___________________________________________________________

Telephone:  _________________________________________________________

Fax:  ______________________________________________________________

Date hired:  ______________________        Date Separated:  _________________

Annual Income:  __________________

Please list all positions held from hire date to discharge date (or presently if still employed):

Position #1 _____________________________________   Dates:  ___________________________

Position #2) _____________________________________  Dates:  ___________________________

Position #3) _____________________________________  Dates:  ___________________________

Position #4) _____________________________________ Dates:  ___________________________

Position #5) _____________________________________  Dates:  ___________________________

List all supervisors and managers from immediate supervisor to head of company for each above described position:

Position #1:     _____________________________________________________________________

Position #2:     _____________________________________________________________________

Position #3:     _____________________________________________________________________

Position #4:     _____________________________________________________________________

Position #5:     _____________________________________________________________________

Please provide the telephone and fax number for the human resources department (if applicable):

How many hours did you work per week on average?  ______________________

Please provide a job description of your duties with the company:

Were you ever denied a promotion?  If so, please explain:

Were you ever suspended?  If so, please explain:

 Were you ever disciplined?  If so, please explain:

 Were you ever reprimanded either orally or in writing?  If so, please explain:

Did you ever receive an employee handbook or similar documentation?  If so, please explain when you received such documents and bring them to our meeting in date order:

Please describe any other employment documents you have and bring any documentation to our meeting in date order:

Do you feel you were harassed or discriminated against for any reason?  If so, please describe each situation and who you reported the conduct to if anybody:

Did you ever report this conduct to any governmental agencies?  If so, please explain:

Were you totally truthful on your employment application?  If not, please explain:

Have you ever been treated by a doctor for stress related reasons either as a result of work or otherwise:  If so, please explain:

Why are you no longer with the company?

Please provide a detailed explanation of your situation by date from earliest to present:

PART III.  WITNESSES

List all potential witnesses favourable to your case:

List all potential witnesses unfavourable to your case: