Questionnaire

I. Employee Data:

                Last Name                  First Name          M.
Name:         
Address:  
City:      State Zip
Home:      Cell: Work:
Email:    

II. Employer Data

                Last Name                  First Name          M.
Name:         
Address:  
City:      State Zip
Immediate Supervisor's Name:
Date Hired(mm/dd/yy):
Date Employment Terminated (mm/dd/yy):
Job Title: Rate of Pay:

III. CIRCUMSTANCES OF TERMINATION

Fired? -- Select -- Yes No Any Notice? -- Select -- Yes No # Days: Quit? -- Select -- Yes No
#Days Notice of Intent to quit
Last Day of Work(mm/dd/yy): Any Written Employee Agreement: -- Select -- Yes No
When Last Wages Received(mm/dd/yy: Union Member: -- Select -- Yes No

IV. WAGES RECEIVED

Work Off the Clock? -- Select -- Yes No Ave # Hours per Day:
Work Overtime? -- Select -- Yes No Ave # Hrs Worked/Week
Overtime Rate Paid:
Vacation Hrs:
Other Facts: