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MICHAEL A. JACOBSON, P.S.
119 FIRST AVENUE SOUTH, SUITE 200
SEATTLE, WA 98104
(206) 447-1560
FAX (206) 447-1523
mike@mikejacobsonlaw.com
______________________________________________________________________________________________
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NOTE ON USE: The answers given to the questions which follow are intended solely for the use of the
Law Firm of Michael A. Jacobson, P.S. The same are made for the purpose of seeking legal advice from
Michael A. Jacobson, PS about a current or anticipated dispute and are to be used for no other purpose. If
you received this communication in error, please deliver it to the address marked above and destroy any
copies of the same.
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Return to Home Page
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1. Personal profile
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Name
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Address
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Cell/Pager
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Phones Daytime
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Evening
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2. Employer with whom you have dispute
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Company name
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Address
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Facility at which you worked
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Approximate number of persons employed by company within Washington State
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First-level supervisor name and title
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Second-level supervisor name and title
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Third-level supervisor name and title
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Supervisor or other person with whom you have dispute at work
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3. Characteristic for which you are picked on, singled out, excluded or discriminated against
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Race/Color
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Age
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National Origin or accent
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Religion or creed
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Disability
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Sexual Orientation
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Gender
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Pregnancy
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Reporting Harm to Public Safety
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Reporting Harm to Public Health
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Union Activism
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Reporting harm to other public interest (specify what interest)
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Fair tenure or layoff or layoff procedures (in writing)
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Fair Disciplinary Procedures (in writing)
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Other promise written in employee compensation or benefit plan
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Other written promise of fair treatment
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False rumor (specify)
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4. Please describe your most outrageous experience of discrimination
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5. Who else saw it or heard it (or themselves had a similar experience) and will describe it to me?
(Please describe what each knows and how they can be reached.)
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6. Please describe what was said or done and by whom which identifies the characteristic(s) checked above
to be the basis or reason for being badly treated
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7. Who else saw or heard what was said or done above and will describe it to me?
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8. If discharged (disciplined), what reason for terminating your employment (disciplinary action) did the company
manager write down or record in your personnel file or report to the unemployment office?
Where was it recorded?
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9. Identify the data that demonstrates that such a reason is false or has been regarded for others to be trivial.
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10. What record or person has this data establishing the reason to be false?
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11. List here the important documents in your possession that establish the points you’ve reported in 1-10 and
identify in particular who has possession of those which you do not possess.
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12. Are you aware of any time deadlines that create urgency to act? What and when?
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13. What did you need to convey that is not covered in questions 1-12?
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I certify under penalty of perjury under United States Law that my assertions here are true to the best of my knowledge
and belief. I understand that by this submission, I have not secured an agreement to represent me; that the law firm
does not take every case which is submitted for review, and that such agreement to represent will have to be the
product of further communications.
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DATED:
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SIGNED:
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When completed, print and mail to the address
above OR e-mail as an attachment to
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Mike Jacobson
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