Name of business:

Address:

Email address *:

Telephone number:

Title:

First name(s):

Surname:

Date of birth:

Email address:

Telephone number:

Position within business:

What is the name of the employee in question?

Job title

Date of commencement of his/her employment

Date of termination of employment (unless continuing)

Salary

Gross £

per weekmonthyear

Net £

per weekmonthyear

Benefits (please list):

Describe the nature of the dispute with the employee or action which may give rise to a dispute

Has the employee commenced any tribunal action in relation to the above?

YesNo

If so, on what date was the claim filed?

What is the date by which your response is due (if not filed)?

Describe the stage that the proceedings have reached (specify the final hearing date if you have been notified of one)