MICHAEL A. JACOBSON, P.S.
200 MAYNARD BUILDING
119 FIRST AVENUE SOUTH o SEATTLE, WA 98104
PHONE (206) 447-1560 o FAX (206) 447-1523
IMMIGRATION INTAKE: 360-441-4837
michaeljacobsonlaw@gmail.com
NOTE ON USE:    The answers given to the questions which follow are intended solely for the use of the Law Firm
of Michael A. Jacobson, P.S.  The same are made for the purpose of seeking legal advice from Michael A.
Jacobson, PS about a current or anticipated dispute and are to be used for no other purpose. FOR
IMMIGRATION INTAKE, PLEASE CONTACT US AT (360) 441-4837. If you received this communication in error,
please deliver it to the address marked above and destroy any copies of the same.
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1. Personal Profile
Name:
Home Phone:
Cellphone:
Work Phone:
Email address:
Address:
Which of these methods is the best way to reach you?
2. Employer with whom you have a dispute
Company name
Address:
Facility at which you worked
Approximate number of persons employed by company within Washington State
First-level supervisor name and title
Second-level supervisor name and title
Third-level supervisor name and title
Supervisor or other person with whom you have a dispute at work
3. Characteristic for which you are picked on, singled out, excluded, or discriminated against
Age
Race/Color
National Origin or accent
Religion or creed
Disability
 Pregnancy
 Sexual Orientation
Gender
Reporting Harm to Public Health
 Reporting Harm to Public Safety
Union Activism
Reporting harm to other public interest (specify what interest)
Fair tenure or layoff or layoff procedures (in writing)
 Fair Disciplinary Procedures (in writing)
Other promise written in employee benefit or compensation plan
Other written promise of fair treatment
False Rumor (specify)
4. Please describe your most outrageous example of discrimination and what was said or done and by
whom that identifies the characteristic(s) checked above as the basis or reason for being badly treated.
(If you need more space on this or any other question, please attach extra pages to your questionnaire.)
5. Who else saw it or heard it (or themselves had a similar experience) and will describe it to me?
(Please describe what each person knows and how they can be reached.)
6. If discharged or disciplined, what reason for terminating your employment (or disciplinary action) did
the company manager write down or record in your personnel file or report to the unemployment office?
Where was it recorded?
7. Identify the data that demonstrates that such a reason is false or has been regarded for others to be
trivial.
What record or person has this data establishing the reason to be false?
8. List here the important documents in your possession that establish the points you've reported in
1-7, and identify in particular who has possession of those which you do not possess.
9. Are you aware of any time deadlines that create urgency to act?  What and when?
10. What do you need to convey that is not covered in questions 1-9?
I certify, under penalty of perjury under United States Law, that my assertions here are true to the best of my
knowledge and belief.  I understand that by this submission, I have not secured an agreement to represent me,
that the law firm does not take every case submitted for review, and that such agreement to represent me will
have to be the subject of further communications.
Dated:
 Signed: