Employment Questionnaire

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First Name*
Last Name*
Email*
Hidden
Solicitor ID*
Full Legal Name of Employer*
Address where you worked on a daily basis*
Name/Number and Street Address Line 2 Town/City State / Province / Region ZIP / Postal Code Country
Employers Telephone Number*
Date of Birth*
DD slash MM slash YYYY
Job Title*
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Average Weekly Hours*
Rate of pay before tax (£)*
What date did you first find out your were dismissed?*
MM slash DD slash YYYY
What date was the most recent act of discrimination?
MM slash DD slash YYYY

NOTE: This only applies to discrimination cases.
Are you aware of any circumstances, arising from your employment, that may give rise to a personal injury claim?*
Are you owed outstanding salary?*
- Yes
- No
How much? (Salary)*
Are you owed holiday pay?*
- Yes
- No
How much? (Holiday Pay)*
Are you owed notice pay?*
- Yes
- No
How much? (Notice Pay)*
Were you in the pension scheme?*
- Yes
- No
Have you found another job yet?*
- Yes
- No
Start Date*
MM slash DD slash YYYY
Rate of pay (before tax)*
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