Internal Use Only
Date Received _______________________
Date Acknowledged __________________
Staff Review Date _________________
Referral Date ________________________
Survey Date _________________________
Net/Bk _____________________________
Notes _____________________________

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, DC 20027

Facsimile (202) 342-1904

info@whistleblowers.org

Do not send information by express or certified mail, it will delay your referral

This page sponsored by the National Whistleblower

Legal Defense and Education Fund