First Name Last Name Street Address City State Zip Code Email Phone Number Age Gender Male Female Name of Company/Employer City/State Job Title Job Duties (200 chars left) Number of Employees 0-14 15-100 101-200 201-500 500+ How were you paid? Hourly Salary Salary N/A Under $24,999 $25,000 to 49,999 $50,000 to $99,999 $100,000 to $199,999 Over $200,000 Hourly Wage Under $12/hr $12/hr to $20/hr Over $20/hr Adverse Employment Action you suffered from Employer Termination(Involuntary discharge, layoff, forced to quit, constructive discharge) Breach of Contract Harassment (Sexual, Racial, Age, etc.) Passed Over for Promotion Pay Decrease Demotion Failure to Hire Failure to Pay Overtime Other Basis for Adverse Action Sexual Harassment Race, Color, National Origin Gender Age Religion Disability Other Reason Given by Employer for Adverse Employment Action Reason You Believe Motivated the Adverse Employment Action Submit
