Richard J. Gonzalez
Menu
Home
About
Contact
Severance
Harassment
Discrimination
Speeches and Publications
Employment Lawyer
Browse:
Home
»
Contact Richard J. Gonzalez
»
Other Discrimination or Wrongful Discharge
»
Discrimination Form
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
Your job title
Brief description of discriminatory acts by employer:
Describe nature and extent of disability if disability discrimination:
Amount of lost wages suffered:
Under $25000
$25000 to $50000
$50000 to $100000
More than $100000
Best time and method of contacting me is:
Submit
Δ