First Name, Last Name Email Phone Employer Message How did you find us? Are you unionized? Yes No Have you been laid off or terminated? Yes No If yes, was severance offered? Yes No If yes, when do you need to respond by? Start Date Total time working in this ob (years/months) Job Title Responsibility entry-level seasoned staff manager supervisor director executive Number of direct reports (if applicable) Salary Your age If you have a written work agreement, please attach it here Summary of workplace issue Send