Discrimination at Respond Legal

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What is your role in this incident? [required]

Please describe the circumstances of the discriminatory action (location, individuals involved). Keep your description general and do not include names of anyone involved. [required]

Please briefly describe the specific action(s) that you feel constituted discrimination. [required]

Please briefly describe the reason, if any, given for the action(s). [required]

On what basis do you feel that you were discriminated against? Check all that apply: [required]

Age

Disability

Gender

Illness/Injury

Marital Status

National Origin

Pension or Other Benefit Status

Pregnancy

Race

Religion

Retaliation

Sexual Orientation

Union Membership

Workers Compensation Claim

Other:

Please briefly describe the injuries, damages or losses you have suffered as a result of this discrimination. [required]

When did you become aware of the discriminatory action? [required]

Please indicate how you would prefer to to pay for the services of an attorney, should you hire one to help you with your legal matter. Note: there is no charge to sumbit your request. [required]

Hourly Rate

Retainer

Flat Fee

Contingency

Not Sure

Comments or Details:

I want responses from Lawyers that serve: [required]

10)

ZIP Code:	-- OR --
City/State

Contact Information:

11)

First Name: [required]

Last Name: [required]

12)

Email Address: [required]

13)

Day Time Phone: [required]
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Evening Phone:
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14)

Best Time: [required]

Terms of Service

15)

I acknowledge that I have read and I agree to the TERMS AND CONDITIONS of this service [required]

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