LIVINGSTON, ADLER, PULDA, MEIKLEJOHN & KELLY, P.C.

Submitted by superuser on September 15, 2014 - 10:02am.

CONFIDENTIAL QUESTIONNAIRE

This questionnaire was prepared by Livingston, Adler, Pulda, Meiklejohn & Kelly, P.C. ("the Firm"). It is intended for general information gathering only. By completing this form you are not entering into an attorney-client relationship with the Firm, and the Firm is not making any commitment that it will agree to represent, advise, and/or meet with you.

Please complete this questionnaire as best you can and someone from the Firm will contact you.

ATTORNEY

Are you hoping to speak with a particular Attorney? If so, Who:

If s/he is not available, are you willing to speak with another Attorney?:

PERSONAL DATA

Name:

Street Address:

City/State/Zip:

Best Telephone Number:

Choose an item.:

Alternate Phone Number:

Choose an item.:

Email address:

Choose an item.:

EMPLOYER DATA

Employer:

Employer's Location:

Employer's Approximate Size:

Is employer a public agency or department of the State of Connecticut?:

Specify the name of the agency or department:

UNION MEMBERSHIP / ACTIVITY

Are you/were you a Union member or covered by a Union contract?:

Name of the Union:

Has any grievance been filed about the subject of this inquiry?:

If yes, what is the status of the grievance?:

EMPLOYMENT HISTORY

Postion / Job title:

Date of Hire:

Current Employee:

Name of your supervisor:

Do you have a written employment contract?:

If so, do you have a copy of the contract?:

ATTORNEY DATA

Are you currently represented by an attorney?:

If so, does your attorney know you are contacting another attorney?:

FACTUAL INFORMATION REGARDING YOUR SITUATION

Date that problem/issue began with this employer:

Please select the action that best descibes the issue you are contacting us about:

Do you believe the above action was taken because of:

If the above action occurred on a particular date, please provide:

Name of person(s) who made the decision to take the above action:

BRIEFLY describe the nature of the problem about which you are seeking advice:

Are there any deadlines of which the Firm should be aware?:

If yes, please describe the deadline and give date:

Have you filed any claims or complaints about this situation?:

If yes, where and/or with whom did you file?:

When did you file?:

What is the status of that claim or complaint?:

HOW DID YOU FIND US?:

If you were referred, by whom:

This questionnaire was prepared by Livingston, Adler, Pulda, Meiklejohn & Kelly, P.C. -- the Firm. It is intended for general informational gathering only. By completing this form you are not entering into an attorney-client relationship with the Firm, and the Firm is not making any commitment that it will agree to represent, advise, and/or meet with you.