Richard J. Gonzalez
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Severance Agreements and/or Age Discrimination
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Severance/Age Discrimination Form
Severance/Age Discrimination Form
First Name
(required)
Last Name
(required)
Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
Email
(required)
Date of Birth
Employer Name
Length of Employment
5 years or less
5 to 10 years
11 to 20 years
21 to 30 years
More than 30 years
Have you been<br /> offered a severance package?
Yes
No
If Yes, the agreement offers how many weeks of salary?
Other comments about grounds for a discrimination or wrongful discharge claim:
Best time and method of contacting me is:
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