Consultation Request

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Wage & Hour Form

Thank you for your interest in Thompson, Rollins & Schwartz.

So that we can best determine if we can help you, please fill out the following questionnaire. You may skip those portions of the form that are not relevant to your situation, but be sure to fill in the required fields, marked with an *.

THIS FORM IS COMPLETELY CONFIDENTIAL.
The information you provide to us will not be discussed with anyone but you. Please note that submitting this consultation request form does not mean you have retained us as your attorneys, and TRS reserves the right not to represent you in the matter you have requested that the Firm review.


* Date:
* Name:
* Age:
* How did you find us?
Home Telephone Number:
Work Telephone Number: (If it is OK to call)
Mobile Telephone Number:
Email Address:
Home Address:

* Employer you are contacting us about:
* Hire date:
* Current or Last position held and/or position about which you are inquiring:

The following questions address the position about which you are inquiring:
Brief Description of your job duties:

Does job require a degree or the equivalent?
yes no

Are you or were you paid hourly or a salary?
yes no
If hourly, what is/was your rate of pay per hour?
If salaried, what is/was your annual salary?

If salaried, did you ever receive pay for less than a full day’s work?
yes no
If salaried, what happened to your pay after you used up any sick time?

Do you or did you work over 40 hours per week?
yes no
If yes, how many hours total did you average per week?

Does your employer pay you time and a half for all work over 40 hours a week?
yes no

Are you categorized as an independent contractor?
yes no

Do you believe your employer might owe you overtime compensation?
yes no

Have you been required to work during your lunch break without compensation?
yes no

Have you been required to work “off-the-clock” without compensation?
yes no

Does the job require you to arrive early in order to complete tasks (such as putting on special clothing or preparing equipment for immediate use) without compensation?
yes no

Are you paid in whole or in part on a commission basis?
yes no

Did you complain to your employer about how you were being paid?
yes no

Do you believe that you were or are being retaliated against for having complained about how you were being paid?
yes no
If so, in what way do you think you were retaliated against?
If you are no longer employed, were you laid off,
or fired, or did you quit?
Termination date: (if applicable)

Were you given any severance pay?
yes no

* Did you sign a release?
yes no

* Have you ever signed an arbitration agreement with this employer?
yes no

* Are you currently represented by another attorney on this matter?
yes no
If so, who is the attorney?

Were you previously represented by another attorney on this matter?
yes no
If so, who is the attorney?

* Have you filed for bankruptcy?
yes no

Are you aware of any other lawsuits concerning pay/overtime issues against this employer?
yes no
If yes, what information do you have about any lawsuit(s)?


 
160 Clairemont Ave., Suite 595, Decatur (Atlanta), GA 30030   O: 404-377-7717   F: 404-377-5119
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