Potential Client Questionnaire

Name *
Name
Address *
Address
Cell Phone *
Cell Phone
Alternative Phone
Alternative Phone
Gender
How many employees work for the company / employer *
Were you an employee or an independent contractor?
Are / were you a union member? *
Are you still employed with this employer? *
Has it been more than one year since the above events took place?* *
Have you spoken to, met with, or corresponded with any other attorneys regarding the issue you wish to speak with us about?
Are you disabled? *
Have you ever requested an accommodation of a disability from this employer?
Did you ever complain to your employer regarding their wrongful conduct? *
Do you have any witnesses or documents to help you prove your claims? *
Have you ever taken a leave of absence from work? *
Do you believe you were fired for taking a leave of absence? *
Are/were you paid overtime for working more than 40 hours per week or 8 hours per day? *
Are/were you given a 30 minute off-duty meal break for each 5 hours that you worked: *
Were you reimbursed for work-related expenses (cell phone, uniforms, mileage (other than commuting), travel, supplies, etc.)? *
Have you ever sued anyone before or been sued? *
Have you ever filed or are you thinking of filing for bankruptcy? *
Have you been convicted of a crime in the past 10 years? *
Have you ever filed a workers' compensation claim? *
Do you believe you were fired for filing a workers' compensation claim? *
COMPLAINTS TO GOVERNMENTAL AGENCIESSection
Have you filed a complaint with the Department of Fair Employment and Housing (DFEH) or the Equal Employment Opportunity Commission (EEOC)? *
If yes, have you received a Right-to-Sue letter?
Have you filed a complaint with the Department of Labor Standards Enforcement ("DLSE"/the Labor Commissioner)? *
Did your employer have you sign an arbitration agreement, either as part of a handbook or given to you as a separate document? *

Note: Although the information you provide to us on this form is confidential, completion and/or submission of this form to us does not create an attorney-client relationship between Shirazi Law Firm (the "Firm") and you. No attorney-client relationship shall exist until you and the Firm make a mutual decision to work together and make a written agreement stating the specific terms of that attorney-client relationship. While this questionnaire does not create an attorney client relationship, your information will be confidential and privileged. We will not disclose your information and you may not be compelled to disclose your communications with us to anyone.

If you have time deadlines (or statutes of limitations) that are quickly approaching, we cannot guarantee that we will respond in time for us to assist you in filing a lawsuit or administrative agency complaint. You should take immediate action to avoid missing any such deadlines.