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NATIONAL WHISTLEBLOWER LEGAL DEFENSE AND EDUCATION FUND
ATTORNEY REFERRAL SERVICE INTAKE FORM
STRICTLY CONFIDENTIAL:
ATTORNEY-CLIENT WORK PRODUCT MATERIAL
Please Print Your Responses.
DATE: ____________________
Please note that some whistleblower protection laws have very short (30 days) statute of limitations. You may need to take immediate action on your own to secure your rights while waiting for a referral. The referral process is designed to supplement other efforts you are taking to obtain counsel. This form is strictly for the purpose of making a referral for
legal counsel and is not a guarantee of legal representation.
Please provide specific dates where possible.
NAME & ADDRESS:________________________________________________________________________ _____________________________________
__________________________________________________________________________________ ___________________________________
__________________________________________________________________________________ ___________________________________
(Phone) ______________________ (Fax) ________________________ Email: ____________________
LIST TWO LARGE CITIES LOCATED NEAR YOUR ADDRESS:
___________________________________________________________
HOW DID YOU LEARN ABOUT OUR ORGANIZATION?
___________________________________________________________
NAME & ADDRESS OF EMPLOYER WHERE YOU EXPERIENCED DISCRIMINATION:
__________________________________________________________________________________ ___________________________________
__________________________________________________________________________________ ____________________________________
__________________________________________________________________________________ ____________________________________
ARE YOU CURRENTLY EMPLOYED?
___________________________________________________________
POSITION HELD:
__________________________________________________________
WHAT DID YOU BLOW THE WHISTLE ON OR WHAT VIOLATION DID YOU REPORT?
(Attach one to two-page typed summary of your case, do not include original documents.)
__________________________________________________________________________________ ____________________________________
__________________________________________________________________________________ ____________________________________
__________________________________________________________________________________ ____________________________________
WHEN AND TO WHOM DID YOU MAKE THIS REPORT?
(Give specific dates and details in your attached summary)
__________________________________________________________________________________ ___________________________________
__________________________________________________________________________________ ___________________________________
WHEN AND WHAT TYPE OF RETALIATION HAVE YOU BEEN SUBJECTED?
(Give specific dates and details in your attached summary)
__________________________________________________________________________________ ___________________________________
__________________________________________________________________________________ ___________________________________
__________________________________________________________________________________ ___________________________________
DO YOU CURRENTLY HAVE AN ATTORNEY? _____ Yes _____ No
If yes, give name of attorney and firm representing you:
___________________________________________________________
DO YOU HAVE A CASE PENDING BEFORE A COURT? _____ Yes _____ No
BEFORE AN ADMINISTRATIVE AGENCY? _____ Yes _____ No
If Yes, give name of case and current status:
__________________________________________________________________________________ ____________________________________
DO YOU WANT A REFERRAL? _____ Yes _____ No
(Any fee arrangements are between you and the referred attorney, we cannot guarantee
the attorney will accept your case or the type of fee arrangement they will offer.)
Can The NWLDEF send a copy of this form to the referred attorney? ___Yes ___No
Can The NWLDEF discuss your case with members of the media? ____Yes ____No
THANK YOU FOR COMPLETING THIS FORM AND E-MAILING, MAILING OR FAXING IT TO THE ADDRESS BELOW.
MARK INFORMATION "CONFIDENTIAL ATTORNEY INFORMATION."
SEND NO MORE THAN TWO ADDITIONAL PAGES OF EXPLANATION.
DOCUMENTS WILL NOT BE RETURNED.
PLEASE DO NOT ENCLOSE ANY ORIGINAL DOCUMENTATION.
YOU WILL BE CONTACTED IF MORE INFORMATION IS NEEDED.
Project Manager
National Whistleblower
Legal Defense and Education Fund
P.O. Box 3768
Washington, DC20027
Facsimile (202) 342-1904
contact@whistleblowers.org
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