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1
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Title
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2
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First name(s)
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3
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Surname
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4
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Date of birth
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5
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Email address
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6
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Telephone number
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7
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What is the name of your employer/former employer?
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8
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Date of commencement of employment
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9
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Date of termination of employment (unless continuing)
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10
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Salary
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11
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Benefits (please list)
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12
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Did you resign or did your employer terminate your contract of
employment?
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13
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What was the reason given?
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14
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Did you appeal?
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15
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What do you say about the circumstances in which your employment ended?
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16
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Were you subjected to any disciplinary action?
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17
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Describe the allegations against you
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18
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What do you say about the allegations?
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19
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Have you attended a disciplinary hearing?
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20
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If yes, what was the outcome?
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21
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Do you have any earlier disciplinary warnings on your record?
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22
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If so, on what dates were they issued and what for (identify all)?
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23
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Have you since got another job?
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24
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When did you start the job?
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25
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How much do you earn?
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26
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Are you owed any money by your employer?
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27
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What are you owed the money for
[e.g. wages, commission, expenses etc.]
[If so, answer questions 28 and 29 below]
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28
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How much are you owed?
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£
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29
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Describe here any additional complaints
you have against your employer
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30
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Have you submitted a grievance to your employer?
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31
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Describe the outcome
[If necessary, put “No outcome yet”
if, for example, you are awaiting a grievance meeting]
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32
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Have you commenced any tribunal action in relation to the above?
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33
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If so, on what date did you file your claim?
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34
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Describe the stage that the proceedings have reached
(specify the final hearing date if you have been notified of one)
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35
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Do you have legal expenses insurance as part of your
insurance policy that you have (e.g. home buildings or contents
policies).
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