EMPLOYMENT INTAKE FORM

Client Information

Date of Birth



Prior felony convictions? YesNo
Any Arrests? YesNo

Employer Information

Hire Date




Are you a member of a Union? YesNo

Wrongful Termination; Discrimination; Harassment; Retaliation

Were you injured while working? YesNo

Do you have a workers’ compensation attorney? YesNo

Meal Periods, Rest Breaks, & Other Issues

Did you receive 30-minute uninterrupted lunch breaks during every shift you worked? YesNo

Was your meal break always taken at this time? YesNo

Did you sign any documents waiving your right to meal breaks? YesNo
Could you leave the premises during your meal break? YesNo
Were you given 10-minute rest breaks every 4 hours? YesNo



Was a credit check ever performed upon hire or at any time during your employment? YesNo

Uniform and Expenses

Uniform? YesNo

Did you pay for it? YesNo

For reduced hours, is it individually, or is it everyone? --SELECT ONE--IndividualEveryone