Intake Form
First Name
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Last Name
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Primary Contact Number
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Your Personal (Not Work) Email Address
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Your Home Mailing Address
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City
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State
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Postal Code
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Residence Address (if different from Mailing Address)
Employer Name
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Employer City and State
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How many employees do you think work for this employer (just take your best guess)
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Less than 5
6-10
11-19
20-50
51-74
More than 75
Last date of adverse action
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Did You Sign an Arbitration Agreement with the Employer?
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Yes I did
No I did not
I am not sure
Have You Ever Filed for Bankruptcy?
Yes
No
I'm Not Sure
Have You Ever Filed a Lawsuit Before?
Yes
No
I'm Not Sure
Briefly tell me about your legal concerns.
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I agree to receive communications by text message related to this inquiry. Frequency of text messages may vary. Messaging and data rates may apply. If you receive a text from us and no longer wish to accept texts, text STOP and we will stop texting you. Text HELP for more information.
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