CLIENT INTERVIEW-INTAKE SHEET

EMPLOYMENT
DATE:______
NAME:___Carlos Melcer____
HOME ADDRESS:4050 Palm Dr., Bonita CA
PHONE: (H)510-812-506___

91902___

(W)______________________

e-mail address: carlosmelcer@yahoo.com__

DATE OF BIRTH: 4/15/67 SOC. SEC. NO 549-99-8617
REFERRED BY:__Jacobo Melcer_______________
EMPLOYER: _Masterimage3d________________________
ADDRESS: __5300 Melrose Av. West Office Building 4th
Floor, Hollywood Ca

90068_____________

NATURE OF BUSINESS: _3D Technology_____________________

NATURE OF DISPUTE (Client's View)_____
_______________________________________________________
EXPLAIN PRIOR LAWSUIT INVOLVEMENT:_____________________
_______________________________________________________
_______________________________________________________
DATE OF HIRE: _11/22/11 DATE OF TERM: ___________
INITIAL JOB TITLE: ____________________________________
LAST JOB TITLE: _______________________________________
STARTING SALARY: ____________ ENDING SAL. _____________
STARTING SUPERVISOR: __________________________________
ENDING SUPERVISOR: ____________________________________
DID CLIENT RELOCATE: __________________________________
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GIVE UP ANOTHER POSITION/OFFER:________________________

RELY ON ANY PROMISE: __________________________________
JOB TITLE/DESCRIPTION AT TIME OF TERMINATION___________
_______________________________________________________
ENDING SALARY: ________ LAST SUPERVISOR: ______________
WHO FIRED CLIENT:_________________
OTHER PERSONS PRESENT AT TERMINATION OR OTHER
ACTION:________________________________________________
REASON GIVEN: _________________________________________
_______________________________________________________
REAL REASON FOR TERM.: ________________________________
_______________________________________________________
WERE YOU TERMINATED FOR SOMETHING YOU DID OUTSIDE OF
WORK? (IF YES, WHAT?)__________________________________
_______________________________________________________
NAME AND TITLE OF PERSON WHO MADE DECISION TO
TERMINATE: ____________________________________________
INCIDENT THAT TRIGGERED: ______________________________
_______________________________________________________
INVESTIGATION? _________
_____________________

BY WHOM:

RESULT:

_______________________________________________
WRITTEN REPORT? _______________________________________
FAVORABLE WITNESSES: __________________________________
_______________________________________________________
UNFAVORABLE: __________________________________________
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WAS CLIENT GIVEN PERFORMANCE WARNINGS, SUSPENDED, OR

DEMOTED: ______________________________________________
_______________________________________________________
CRITICISM OF WORK: ____________________________________
AWARDS, BONUSES: ______________________________________
_______________________________________________________
WHAT'S IN PERSONNEL FILE? _____________________________
_______________________________________________________
HOW WAS OVERALL RATING? _______________________________
HAS CLIENT A COPY OF PERSONNEL FILE: __________________
WAS THERE A WRITTEN CONTRACT? _________________________
TERMS: ________________________________________________
STOCK OPTIONS: ________________________________________
WRITTEN POLICIES/ PROCEDURE MANUAL: ___________________
_______________________________________________________
DID EMPLOYER HAVE PROCEDURES FOR:
EVALUATIONS: ____________ WARNINGS: ____________
REVIEWS: ________________ FIRING: ______________
CORRECTIVE COUNSELING:_________________________________
ANY ORAL PROMISES: ____________________________________
_______________________________________________________
TERMINATED ONLY FOR A CERTAIN REASON: _________________
_______________________________________________________
WAS CLIENT TOLD HE/SHE HAD A FUTURE WITH THE COMPANY:
_______________________________________________________
CLIENT WOULD BE PROMOTED BASED ON PERFORMANCE:
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_______________________________________________________
_______________________________________________________
ANY COMPENSATION BENEFITS: ____________________________
_______________________________________________________
DID EMPLOYER TREAT YOU OR OTHERS UNFAIRLY? ____________
_______________________________________________________
_______________________________________________________
INTERFERE WITH YOUR PERSONAL LIFE? ____________________
_______________________________________________________
INTERFERE WITH FREEDOM OF SPEECH?______________________
_______________________________________________________
RETALIATE FOR YOUR CRITICISM OF EMPLOYER: _____________
EXPLAIN:_______________________________________________
_______________________________________________________
DID EMPLOYER ASK CLIENT TO DO ANYTHING ILLEGAL OR
IMMORAL? ___ EXPLAIN: _____________________________
_______________________________________________________
_______________________________________________________
DID YOU EVER COMPLAIN ABOUT SAFETY OR OTHER WORKING
CONDITIONS TO ANOTHER COMPANY REPRESENTATIVE OR OUTSIDE
PARTY/AGENCY?__________________________________________
EXPLAIN: ______________________________________________
_______________________________________________________
TO WHOM WAS COMPLAINT MADE? ___________________________
DATE OF COMPLAINT: ____________________________________
OUTCOME: ______________________________________________
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DID EMPLOYER RETALIATE FOR THIS COMPLAINT? ____________

_______________________________________________________
DOES EMPLOYER DISCRIMINATE IN TERMS OF:
REFUSAL TO HIRE: ___________

WAGES: __________________

PROMOTION: ______________ PRIVILEGES: _________________

TRAINING: _______________ TERMS OF EMPLOY._____________
HARASSMENT ON THE JOB: ________________________________
DOES CLIENT FEEL DISCRIMINATED AGAINST BECAUSE OF:
RACE: _____________________ RELIGION: _________________
SEX OR PREGNANCY: _________ HANDICAP: _________________
NATIONAL ORIGIN: __________ ANCESTRY: _________________
MARITAL STATUS: ________ SEXUAL PREFERENCE_____________
MEDICAL CONDITION: ________ AGE: ______________________
HAS CLIENT FILED COMPLAINT WITH DEPT. FAIR EMPLOYMENT
AND HOUSING AS TO THE DISCRIMINATION? WHEN:
___________________

RESULT: __________________________

ANY OTHER EMPLOYMENT RELATED CLAIMS FILED: ____________

WHEN: ________

RESULT: __________________________

IS CLIENT PRESENTLY EMPLOYED: _________________________

SINCE WHEN: _____________

SALARY:____________________

EMPLOYER'S NAME AND ADDRESS:__________________________

_______________________________________________________
COMPARABLE POSITION: __________________________________
BENEFITS: _____________________________________________
IF NOT EMPLOYED IS CLIENT SEEKING NEW EMPLOYMENT?
_______________________________________________________
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HAS TERMINATION/DISCRIMINATION AFFECTED HEALTH OR

PERSONAL LIFE? ________________________________________
HOW:___________________________________________________
_______________________________________________________
PRESENTLY UNDER A DEAR.'S CARE:
_________________________
WHY? ___________________ NAME OF DR. __________________
MEDICATION: ___________________________________________
HAS CLIENT SPOKEN WITH ANYONE AT CO. __________________
DETAILS: ______________________________________________
_______________________________________________________
HAS CLIENT TRIED TO GET RECOMMENDATIONS: ______________
RESULTS: ______________________________________________
DOES CLIENT KNOW IF POOR RECOMMENDATION WAS PROVIDED TO
PROSPECTIVE EMPLOYER? _________________________________
EXPLAIN: ______________________________________________
_______________________________________________________
HAS CLIENT CONSULTED WITH OTHER ATTORNEYS? ____________
WHO? __________________________________________________
WHAT WOULD CLIENT LIKE TO HAPPEN? _____________________
_______________________________________________________
_______________________________________________________
CHRONOLOGY OF IMPORTANT EVENTS:
HIRED: _____________PROMOTED/DEMOTED: ____________
IMPORTANT EVENT NO. 1: _______________________________
______________________________________________________
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_______________________________________________________
_______________________________________________________
IMPORTANT EVENT NO. 2: _______________________________
______________________________________________________
_______________________________________________________
_______________________________________________________
IMPORTANT EVENT NO. 3: _______________________________
______________________________________________________
_______________________________________________________
_______________________________________________________
IMPORTANT EVENT NO. 4: _______________________________
______________________________________________________
_______________________________________________________
_______________________________________________________
IMPORTANT EVENT NO. 5: _______________________________
______________________________________________________
_______________________________________________________
_______________________________________________________
LAST IMPORTANT EVENT: _______________________________
______________________________________________________
_______________________________________________________
_______________________________________________________

OVERTIME QUESTIONNAIRE
1.

Do you work overtime? __________________

2.

Are you paid at least time and one-half your regular rate of pay for all of this overtime?
________________________________________________

3.

Do you know why your employer doesn=t pay you overtime? If so, explain what you
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have been told?

_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
4.

What is your position or title in your job? _____________________________

5.

In any given day, describe your routine tasks and/or job duties.

_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
6.

On average, how much overtime (in excess of 40 hours per week) do you put in a week?
In a month? In a year? _____________________________

7.

Are any of your co-workers in the same position as you? Approximately how many?
_______________________________________

PLEASE FILL OUT THE DFEH COMPLAINT FORM