Sherinian & Walker Law Firm



Sherinian & Walker Law Firm

A Partnership of Professional Corporations

302 Neptune Building

4401 Westown Parkway

West Des Moines, IA 50266-5945

Mark D. Sherinian, P.C. Telephone (515) 224-2079

Pamela J. Walker, P.C. Facsimile (515) 224-2321

Website:

E-Mail: sherinianlaw@

Date: _____________________________

Case Referred by: _______________________________________________________

Attorney Fee Contract Signed______________________________________________

Medical Authorization Signed ______________________________________________

GENERAL INFORMATION

1. What is your full name? ______________________________________________

2. What is your date of birth? ____________________________________________

3. What is your Social Security Number? __________________________________

4. What is your spouse’s name? __________________________________________

5. What is you current address? __________________________________________

6. What is your home phone number? _____________________________________

7. What is your work phone number? _____________________________________

8. What is your cell phone number? ______________________________________

9. Have you ever used a name different than the one above? If so, what was the name and why? ____________________________________________________

10. Give the name and birth date of any of your children?

______________________________________________________________________________________________________________________________________________________________________________________________________

11. List all the residences that you have lived at in the last ten (10) years.

______________________________________________________________________________________________________________________________________________________________________________________________________

12. Are you married? __________________________________________________

If so, how long have you been married? _________________________________

Date and Place of Marriage ___________________________________________

13. Have you been married previously? ____________________________________

If so, please list your former spouse(s), and list when and where you were previously married.

______________________________________________________________________________________________________________________________________________________________________________________________________

14. List the names of any individuals who are dependent upon you.

______________________________________________________________________________________________________________________________________________________________________________________________________

15. Have you ever been arrested for any type of crime (except for minor traffic violations.) If so, what was the crime, where did this occur, was this a misdemeanor or felony, were you convicted, etc. __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

16. Have you ever been involved in a lawsuit before? If so, what type of lawsuit, where was it filed, were you the Plaintiff or Defendant, what is the disposition of this lawsuit? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

17. Please provide a list of names, addresses and telephone numbers of individuals who may be in any way helpful in this case. Please explain how this person knows this information, their relationship to you, and what type of information each person knows. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

18. Please provide a list of any documents that personally have in your possession that in any way may be helpful to your case. Please provide us a copy of these documents upon your completion of these questions. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

EDUCATION

19. Describe your education, both formal and informal. Include any schools attended, highest grade completed, approximates dates of attendance and any awards or certificates garnered.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

WORK BACKGROUND

20. State the name and address of your employer. ____________________________________________________________________________________________________________________________________

21. What was your job title? _____________________________________________

22. What did your job entail? (Describe your average, routine day.)

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

23. What were the hours that you worked? __________________________________

24. What was your rate of pay? ___________________________________________

25. How much overtime did you earn last year? ______________________________

26. How much did you receive last year in bonuses? __________________________

27. When did you first start working for your employer? _______________________

28. Who hired you at your employer? ______________________________________

29. Are you still working for this employer? _________________________________

30. If you have changed employers, for whom are you currently working, and when did you start working there?

__________________________________________________________________

31. If you are still working for this employer, has your rate of pay been increased or decreased? If so, how much? ____________________________________________________________________________________________________________________________________

32. Have you had any disciplinary problems with the company? ____________________________________________________________________________________________________________________________________

33. Do you received regular evaluations at the employers? ____________________________________________________________________________________________________________________________________

34. Were you working on a contract basis? If so, when did you sign the most recent contract? How long did the contract run for? ____________________________________________________________________________________________________________________________________

35. Are you a member of a union? If so, which union? __________________________________________________________________

36. Has the union done anything for you? __________________________________________________________________

37. Have you been terminated? If so, when were you terminated? __________________________________________________________________

38. What were the reasons given for the termination? ______________________________________________________________________________________________________________________________________________________________________________________________________

39. Are those reasons correct or incorrect? Please explain. ______________________________________________________________________________________________________________________________________________________________________________________________________

40. Have you signed any documents when you were terminated? If so, what documents did you sign? ______________________________________________________________________________________________________________________________________________________________________________________________________

41. Have you been given any sort of severance package? If so, what are the terms? ______________________________________________________________________________________________________________________________________________________________________________________________________

42. How many employees worked for the company? __________________________________________________________________

43. Please list any the name, address and phone number for any employers that you worked for prior to working for the one listed above. Please also give the approximate dates that worked there, your rate of pay, and the reason for leaving said employer. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

44. Please list any the name, address and phone number for any employers that you worked for after working for the one listed above. Please also give the approximate dates that worked there, your rate of pay, and the reason for leaving said employer. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

45. State the significant dates of your employment and describe what events occurred on that date. (Use an additional sheet of paper if necessary.)

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