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Employment Web Intake Form

Name *

Age

Cell Phone *

Home Phone

Work Phone

Email Address *

Street Address

City *

Province

Postal Code

If you are contacting us on behalf of someone else, please provide that person’s full name, date of birth and your relationship to that person

What is the name of your employer? *

When did you start working for this employer?

The date your employer terminated your employment? *

What position did you hold at the time of your dismissal?

The reason your employer provided for terminating your employment? *

What was your approximate gross weekly income at the time your employer terminated your employment:

Did your employer pay you any severance pay or dismissal pay when you employment was terminated? If yes, how much?

Did your employer ask you to sign any paperwork? If yes, please describe what your employer asked you to sign.

Are you part of a union? Yes No

If yes, have you filed a grievance with your union?

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