Title:

Your name:

Date of birth:

Your email address:

Your telephone number:

What is the name of your employer/former employer?

Date of commencement of employment:

Date of termination of employment (unless continuing):

Salary:

Benefits (please list)

Do you consider that you have been discriminated against by reason of your sex, race, age or disability or other reason

YesNo

What is your characteristic which you
consider has given rise to this discrimination?
[e.g. sex – female, race – black African, age – in my 60s,
disability – multiple sclerosis etc.]

Describe in full what you consider to have constituted discrimination?

Are you owed any money by your employer?
[If so answer questions below]

YesNo

What are you owed the money for
[e.g. wages, commission, expenses etc.]

How much are you owed?

Describe here any additional complaints
you have against your employer

Have you submitted a grievance to your employer?

YesNo