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

()

 

Email

 

How would you like us to contact you?

 Telephone Email

 

Please give us some background information regarding your individual situation

 

Is there any other information that we should be aware of?

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