Client Intake Short Form Please fill out this Employment Law questionnaire as much as you can so we can evaluate your case.Your Current Address* City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Your Name* First Last Your Email* Your Phone NumberYour Age*Identify the employer with whom you have a problem.*State the employer's physical address where you worked.*How large is the employer?*1-5 employees6-50 employeesMore than 50 employeesWhen did you start working for the employer?* Date Format: MM slash DD slash YYYY When was your actual last day of work?* Date Format: MM slash DD slash YYYY Describe your job duties.*Describe your compensation structure.*HourlySalaryCommissionsFlat fee per dayPiece rate based on number of units performed.What was your hourly rate during the last pay period?What is your annual gross compensation?Less than $50,000$50,000 - $100,000More than $100,000What was your classification?* I was classified as an employee and employment taxes were deducted from my paycheck. I was classified as an independent contractor and received a 1099 form. I was classified as an employee and independent contractor. Not sure. Are you a member of a union?*Yes, I am a member of a union.No.Not sure.Please tell us why you are looking for an employment attorney and any additional information that may help us to evaluate your case.*Consent* I agree to the below terms.By submitting this form you acknowledge and understand that the use of this form in no way creates an attorney-client relationship with Kuchinsky Law Office, PC or Alexei Kuchinsky. An attorney-client relationship will only come into being between you and Kuchinsky Law Office, PC only if you and Kuchinsky Law Office, PC enter into a written fee agreement that is prepared by Kuchinsky Law Office, PC. If you have any questions regarding this disclaimer please contact our office at (628) 200-0902.NameThis field is for validation purposes and should be left unchanged.