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Name:
E-Mail:

Address:

City: State:

Zip Code:

Home Telephone Number:
Work Telephone Number:
Employer:
Your Job Title:
Your Job Duties:

Are you paid:

 

(please check one)

by the hour?

on a salary?

What is your approximate rate of pay?
What is your highest level of education?
My employer classifies me as:

an exempt employee?

a non-exempt employee?

do not know

In the past four years, how many hours have you worked in excess of 40 hours per week, for which you were not paid overtime?

Which of the following are true?

My employer has a policy or practice of refusing to pay overtime

I work overtime, but my employer won't pay overtime unless it is pre-approved

My employer makes me work through lunch breaks or rest periods

My employer pays me a salary, but deducts from my pay if I miss work or make a mistake

My employer calls me an "independent contractor" to avoid paying overtime for other employment benefits

My employer calls me a "salaried" or "exempt" employee, but I spend more than 50% of my time doing routine work

Is there any other information we should know to properly evaluate your claim: