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The Pink Form The Obesity Law and Advocacy Center
Contact Form
Discriminated Against
Based on Size
     PLEASE FILL OUT THIS FORM IF YOU BELIEVE YOU HAVE BEEN DISCRIMINATED AGAINST BASED ON YOUR SIZE IN YOUR WORKPLACE.

(THIS FORM IS ENCRYPTED ON A SECURE SERVER FOR YOUR PRIVACY)

     Thank you for your interest in the Obesity Law and Advocacy Center. If we can be of any assistance or if you need to contact us via email, please fill out the form below and we will contact you as soon as possible.

Name  
Street address  
Address (cont.)  
City  
State/Province  
Zip/Postal code  
Country  
Work Phone  
Home Phone  
FAX  
E-mail  
How did you hear about us?
 
What company, person, or entity engaged in conduct you believe was
 
discrimination?
 

     WE NEED TO GET SOME INFORMATION ABOUT YOU IN ORDER TO EVALUATE THIS MATTER. WHILE IT MAY SEEM VERY PERSONAL IN NATURE, PLEASE UNDERSTAND THAT IT IS NECESSARY IN ORDER FOR US TO DETERMINE WHETHER WE CAN HELP YOU.
Please identify and describe yourself:
Age  
Gender  
Male Female
Height  
Weight  
What was your weight at the time of this incident?
   
 
Were you terminated from your employment?
 
Yes
 
No
       
If yes, give the last day of employment:
 
Please briefly describe the circumstances of your termination from
 
employment and explain why you believe it was due to your size:
   
Did you not get hired or promoted for a job because of your size?
 
Yes
 
No
       
If yes, what was the date you were informed you would
 
not be hired
 
Please briefly describe the circumstances of why you were not hired or
 
promoted and explain why you believe it was due to your size:
   
 
Have you filed any formal complaints (also called a "charge of
 
discrimination") with either a state agency or the Equal Employment
 
Opportunity Commission (EEOC)?
 
Yes
 
No
       
If yes, what is the status of that proceeding?
   
 
 
Do you have an attorney representing you currently?
 
Yes
 
No
       
If yes, please provide his/her name, address, and phone number:
   
Can we contact this attorney?
 
Yes
 
No
    
Form may take a moment to process.   Your patience is appreciated.
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Obesity Law & Advocacy Center
1392 East Palomar Street
Suite 403-233
Chula Vista, CA 91913
 
 
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Mail Address: Obesity Law & Advocacy Center, 1392 East Palomar Street, Suite 403-233, Chula Vista, CA 91913
Telephone:  619.656.5251 FAX:  619.656.5254
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