Richard J. Gonzalez Richard J. Gonzalez
Richard J. Gonzalez
Employment Lawyer

Severance/Age Discrimination Form
First Name:       Last Name:
Address:
City:    State:    Zip:
Home Phone:            Work Phone:
Cell Phone:        E Mail Address:
Fax Number:            Date of Birth:
Employer Name:
Length of Employment: 5 Years or Less
5 to 10 Years
11 to 20 Years
21 to 30 Years
More than 30 Years
Have you been
offered a severance package?		 Yes  No
If Yes, the agreement
offers how many weeks of salary?
Other comments about
grounds for a discrimination
or wrongful discharge claim:
Best time and method
of contacting me is:
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©2002 Chicago-Kent College of Law, Illiniois Institute of Technology
565 W. Adams St., chicago, Illinois 60661-3691
Tel 312.906.5079; Fax 312.906.5299

Law Offices: rgonzale@kentlaw.edu