About You
What is the Company’s name?
What does the company do?
Is the company located in Ontario
Yes No
Full Name
How old is the employee?
The employee’s position was/is
How many years has the employee worked for the company?
The employee was a supervisor or manager
Yes No
The employee was/will be terminated because:
Does the employee have a written employment contract/letter?
Yes No
Is the employee a member of a trade union?
Yes No
Contact Information
Full Name
Address
Home Phone Number
() –
Alternate Phone Number
() –
How would you like us to contact you?
Telephone Email
Please give us some background information regarding your individual situation
