Report

All personal information will be kept confidential regarding contacts, unless otherwise authorized. We ask for contact information in order to contact those with potential financial assistance should this effort produce what we are praying it does. With your permission and authorization, we may publish your personal stories in order to get your story told. Part of our mission is to give a voice to those who have been denied their God-given constitutional rights. Your personal information will stay confidential. Anyone wishing for their story to be highlighted will be identified by first name and location ONLY. Additionally, the only portion of your submitted form that would be published is your personal story/other pertinent information field.

First Name*

Last Name*

Phone*

Email*

Address*

City State / Province / Region Postal / Zip Code Country

Highest level of education or certification*

Industry*

Current Employment Status*

Former Occupation*

Former Other Occupation

Employer Name*

Employer Website

Date of Dismissal from former employer*

Number of years with former employer*

Were you officially terminated?*

Yes

Annual income at previous job at time of dismissal*

Current occupation annual pay decrease or increase amount*

Current Occupation (if any)*

Other Current Occupation

Any other pertinent info you feel necessary (ie attempts made to avoid, personal stories, exemption status, etc)

May we publish your story? We would only publish first name and location only, without any information on the establishment that fired you. *

Yes

Prove You are Human