Consultation Request
Thank you for your interest in Schwartz Rollins, LLC.
If you are an employer seeking advice on employment issues, please contact Jay Rollins at 404.844.4132. If you are an employee please continue.
So that we can best determine if we can help you, please fill out the following questionnaire.
*All fields are required. If a field does not apply to your employment situation, put “not applicable” or “n/a” as a response.

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. We reserve the right not to take the case which you are requesting us to review.

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* Required information.
Date (mm/dd/yyyy): *
Name: *
Mobile Phone Number (xxx-xxx-xxxx): *
Email Address: *
Home Address: *
Who Referred You to Us *
Employer You Are Contacting Us About *
Number of Employees *
Your Hire Date* (mm/dd/yyyy):
Current or Last Position Held *
Race: *
Your Current Age: *
Please Check All That Apply: *
I am not being paid earned overtime or have other pay issuesI have been discriminated againstI am being sexually harassed and need helpI am being denied my rights under the Family and Medical Leave ActI have a severance package that needs to be reviewedI am a small employer seeking representationI am charged with sexual harassment and need to be defendedI am a public employee whistleblower
Has an EEOC Charge Been Filed: *
If Yes, Date Filed (mm/dd/yyyy):
Has a Right To Sue Letter Been Issued: *
If Yes, Date Issued (mm/dd/yyyy):
Have You Seen A Healthcare Provider As A Result of Your Employment Situation? *
Are You Or Were You Paid Hourly Or A Salary: *
What Was/Is Your Salary Or Hourly Rate? *
Do You Believe You Might Be Entitled To Seek Overtime Compensation? *
Are You Still Employed? *
Are You Currently On Medical Leave? *
If So, When Did The Leave Begin? (mm/dd/yyyy)
What Is Your Employment Status?: *
Still EmployedLaid OffFiredQuit
Termination Date (mm/dd/yyyy):
If You Were Fired Or Laid Off, What Was The Reason Your Employer Gave? *
If You Do Not Believe Your Employer's Reason, What Do You Believe Happened? *
Were You Given Any Severance Pay? *
If So, How Much?
Did You Sign A Release? *
Have You Been Replaced? *
What Is The Race, Sex, And Age Of Your Replacement?
Do You Believe You Are/Were Getting Paid Less Than Others Doing The Same Work? *
YesNo
Explain: *
If You Believe That You Were Discriminated Against, Please Check All That Apply: *
If You Marked Other, National Origin, Age, Race, or Disability Please Explain: *
What Makes You Believe You Have Been Discriminated Against? *
Brief Description Of The Events Leading You To Contact Us: (Please Be Detailed) *
Date Of The Most Recent Event Described Above (mm/dd/yyyy): *
Are You Complaning About Sexual Harassment? *
If So, Describe The Harassing Behavior:
Did You Complain To Management About Your Issue(s)? *
If So, To Whom Did You Complain:
SupervisorDistrict ManagerHR (Human Resources)Other
Do You Believe That You Have Been Retaliated Against For Mentioning The Issue: *
If So, Describe:
Is There Any Other Info That May Help Us Understand More About Your Claims? *
Do You Have An Employment Contract? *
Have You Ever Signed An Arbitration Agreement With An Employer? *
Have You Ever Signed A Non-Compete or Non-Solicitation Agreement With Employer? *
YesNo
Are You Currently Represented By Another Attorney On This Matter? *
If So, Who Is The Attorney And Why Are They Currently Not Representing You?
Have You Filed For Bankruptcy? *
If Yes, What Date Did You File? (mm/dd/yyyy)

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945 E. Paces Ferry Road, Suite 2270 Atlanta, GA 30326 | 404.844.4130.