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To inquire about your potential employment case, please click here.

To inquire about your potential personal injury case, please click here.

NOTICE:
These forms do not represent a contract between this law firm and the person or company
who submits the following form or forms. They are used for informational purposes only.
The materials on this Web site are made available by The Law Office of John E. Wall, Jr. and do
not constitute legal advice. The exchange of information contained on our web site do not form or
constitute an attorney/client relationship. Anyone who receives or views information on this web site
should not act upon the information without seeking professional legal counsel.

Thank you for your cooperation.

Employment

First Name:
Middle Name:
Last Name:
   
   
Email Address:
Home Phone Number:
Work Phone Number:
Cellular Phone Number:
   
   
Street Address 1:
Street Address 2:
City:
State:
Zip Code:
County:
   
   
Birthdate (mm/dd/yyyy):
Social Security Number:
Drivers License Number
Driver's License State:
   
   
Gender: Male
Female
   
   
Employer Name:
Employer Address1:
Employer Address2:
Employer City:
Employer State:
Employer Zip Code:
Employer County:
Employer Phone Number:
   
   
Please enter your job positions with the above
employer, and the dates you held those positions:
   
   
How many employees does the employer have?:
   
   
Please enter your dates of employment
(beginning and ending, where applicable)
with the above employer, or if you were
denied employment, your date of application
and date of denial:
   
   
Enter ending wage or salary:
   
   
Please enter the full names and addresses of any
witnesses who could support your claim:
   
   
Adverse personnel action: Termination
Retaliation
Wages
Failure to Promote
Failure to Hire
Demotion
Denial of Leave
Job Assignment
Other
   
   
Explain:
   
   
Type of Discrimination: Race
Sex
National Origin
Pregnancy
Breach of Contract
Family and Medical Leave
Filing of Worker's Compensation Claim
Sexual Harassment
Age
Religion
Disability
Other
   
   
Explain:
   
   
Have you filed a charge with the EEOC?: Yes
No
If Yes, enter date filed (mm/dd/yyyy):
   
   
EEOC Charge Number:
   
   
Have you received a notice of right to sue from the EEOC?: Yes
No
If Yes, please specify the date (mm/dd/yyyy):
Have you filed a charge with the TCHR?: Yes
No
If Yes, enter date filed (mm/dd/yyyy):
   
   
TCHR Charge Number:
   
   
Have you received a notice of right
to file a civil action TCHR?:		 Yes
No
If Yes, please specify the date (mm/dd/yyyy):
   
   
If terminated, please enter date (mm/dd/yyyy):
   
   
What reason(s) were you given by the employer
for the adverse personnel action taken against
your (i.e., your termination, demotion, failure to
hire, etc., as applicable)?
Do you believe this is a true reason?: Yes
No
   
   
If not, then what is the reason you feel caused
the adverse personnel action?:
   
   
Name of person who took the adverse personnel action:
Job title of person who took the adverse personnel action:
   
   
Name of person who replaced you (if known):
Race of person who replaced you (if known):
Age of person who replaced you (if known):
Gender of person who replaced you (if known): Male
Female
   
   
What were the results of any perfomance evaluations you received?:
   
   
Were there ever any complaints about your work?
If so, please explain:?:
   
   
Did you have a written or verbal employment contract
or agreement with your employer? If so, please describe the terms: :
   
   
Who referred you to our law firm?:
   
   
Please tell us any other information you believe would help
us in evaluating your claim:

Personal Injury


First Name:
Middle Name:
Last Name:
   
   
Email Address:
Home Phone Number:
Work Phone Number:
Cellular Phone Number:
   
   
Street Address 1:
Street Address 2:
City:
State:
Zip Code:
County:
   
   
Birthdate (mm/dd/yyyy):
Social Security Number:
Drivers License Number
Driver's License State:
   
   
Gender: Male
Female
   
   
Date of Injury (mm/dd/yyyy):
   
   
Describe what happened:
   
   
Name of person or company responsible for injury/death?:
   
   
Set forth the names and addresses of the medical care
providers who furnished medical care to the
injured/deceased:
   
   
Total medical expenses to date:
   
   
If the incident has resulted in lost wages, set forth the
approximate amount of wages lost:
   
   
Names and addresses of any witnesses:
   
   
Any other information which may help in evaluating
your potential case:
   
   
Who referred you to our law firm?: