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.)
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- law firm antiracism alliance skadden
- boutique and specialty practice small law
- top 100 intellectual property law firms
- law firm website fundamentals
- the dillinger law firm
- firm details university of texas system
- internal procedures client intake procedures
- nomination form canadian fintech ai awards 2020
- this application must be signed by a partner officer
- sherinian walker law firm