Wage Claim Intake Checklist (Part 1)

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Personal Information
Client's Name :
Interviewer :
Date of Interview :
Languages spoken :
How did you learn about Bander Law Firm? :
Contact Information
Mobile Number :
Daytime Phone :
Best time to call you during day time :
Evening Phone :
Best time to call you during evening time :
Best number to be able to contact you :
Email :
Employment Information
Name of the employer whom you have a dispute :
Employer's address & phone :
Name of owner :
Name of supervisor :
License plates of owner/supervisor :
Location where work performed :
Date of employment :
How did client hear about the job? :
Name of person who hired client :
Were wages, hours, or working conditions discussed before employment began? :
Promised wages :
Promised hours :
Did the client have a written employment contract :
Job Title/Type of Work :
What exactly did you do? :
Number of employees working for employer :
Name of others who might be witnesses (include why they are witnesses [e.g. "co-worker"] and address/telephone numbers). Note: We would not call anyone without checking first with client. :
Contact information :

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