Date:

Name:*

Address:

Phone:

E-Mail Id:*

Referred by/to:

Summary:

Occupation/Salary/Experience:

Employment Start Date:

Employer:

Number of employees:

Employment Record:

Performance Reviews (copies?):

Termination Date (DOL):

Reason for termination
(Written/Verbal):

Real Reason:

Severance Package:

Has PNC signed severance or anything else

Has there been harassment and/or discrimination? What type?

Culprit(S):

Witnesses:

Has/Did PNC complain about harassment? How—To whom:

Copies of complaint:

Response to complaint:

Did harassment stop after PNC complained:

Is PNC Union:

Union’S Actions:

Does PNC have any disabilities:

Has PNC asked for accommodations:

Have accommodations been granted:

Medical leave:

Dates of med leave:

Doctor’s Name+ Tel:

Has PNC Filed a complaint? -With whom: HR, DFEH, EEOC, ETC.:

Reference:

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