LAYOFF/SEVERANCE PACKAGE QUESTIONNAIRE

Daytime Phone:

*Email:

*City of Residence:

How do you prefer to be contact?
Telephone Email Either

Who is the employer?

*How long have you worked for the employer?

What are/were your position and pay rate?

*Does the employer have more than 15 employees?
Yes No

Have you made a complaint to the EEOC or another government agency, or made a complaint to your employer about problems that arose during your employment, or filed a claim for workers compensation?
Yes No

Are you over 40 years old?
Yes No

What is the effective date of your layoff?

What is the deadline for you to return the severance agreement to the employer?

Does the severance agreement contain a Release?
Choose One Yes No Do Not Know"

Does the severance agreement contain a "non-compete" clause?
Choose One Yes No Do Not Know"

Does the severance agreement provide for stock options as part of the compensation?
Choose One Yes No Do Not Know"

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