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Employment Discrimination - Confidential Questionnaire

Please complete the following questionnaire as thoroughly as possible.

* Denotes a Required Field
Name and Address
First:
 *
Last:
 *
Address:
 *
Address2:
City:
 *
State:
Zip:
 *

Contact Information
Home:
 *
Cell:
Email:
 *
Work:

Personal Information
Birth Date:
 *
Gender:
 *
Birth Place:
U.S. Citizen:
 *
Religion:
 *
Race:
 *
Do you have a disability?:
If 'yes' please briefly explain:
If 'yes' do you have medical documentation?:
Have you declared bankruptcy within the last 7 years?:
If 'yes' under what chapter:

Employment Information
Employer:
 *
Employees:
 # of total employees
Address:
 *
Address2:
City:
 *
State:
Zip:
 *
Date Hired:
 *
Date Fired:

Event Information
Date Event Occurred:
 *
Any Witnesses Names:
(separate names with commas)
Brief Description of Event:
 *


      
PROSPECTIVE CLIENTS

If you are interested in discussing your potential legal claims, please fill out
the questionnaire that best describes your potential claims (i.e., employment discrimination or housing discrimination).
Alternatively, you may fill out the contact form.
The Law Office of Adria Lynn Silva, L.L.C. accepts Title IX; housing discrimination and customer discrimination cases throughout the State of Florida including Alachua, Collier, Lee, Charlotte, Leon, Hillsborough, Orange, Duvall, Palm Beach, Broward, and Miami-Dade Counties and Naples, Ft. Myers, Tampa, Orlando, Ft. Lauderdale, Miami, Jacksonville, Gainesville, Pensacola, and Tallahassee.

Before you decide. "The hiring of a lawyer is an important decision that should not be based solely upon advertisements.
Before you decide, ask me to send you free written information about my qualifications and experience."

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