3 Wembley Court
Albany, New York 12205
Phone: (518) 218-7100
Fax: (518) 218-0496
E-mail: afge@tullylegal.com
Please fill in the following information so that we may
better evaluate your eligibility for a MSPB claim under the Uniformed Services
Employment and Reemployment Rights Act (USERRA).
Once both sheets are completed, please return to our office
via email: afge@tullylegal (send complete
form as an attachment or imbedded document), fax: (518) 218-0496, or postal
mail: Tully, Rinckey & Associates, USERRA Intake, 3 Wembley Ct., Albany, NY
12205. Please allow 2-3 weeks from the time we receive this intake form to
evaluate and start the initial processing of your paperwork. Incomplete,
missing, or vague information may delay the processing of your claim.
Contact
Information:
NAME: ___Mr. ___Ms.
_____________________ญญญ________________________
HOME ADDRESS: ____________________________________
____________________________________
HOME PHONE: ____________________________________
OFFICE PHONE: ____________________________________
CELL PHONE: ____________________________________
EMAIL (home): ____________________________________
EMAIL (work): ____________________________________
Are you currently deployed out of the United States? ___________________________
Military
Service Information:
Beginning Date of Service: ____________________
Ending Date:______________________
Which branch did you serve in? ______________________________________
Any year(s) you did not use any
military leave? _______ญญญญ_________
Did you get charged military leave for non-workdays? ____YES ____NO ____DONT KNOW
Were you forced to use any of the following due to the
agency charging you on off-duty days?
____ Annual Leave
____Sick Leave
____LWOP
Have you filed any other military leave claims with your
personnel office? ___YES ___NO
If Yes,
for which year(s) were you compensated for?
______________
Federal
Civilian Employment Information:
(If
you have been employed by different Federal Departments, Agencies, and/ or
Places of Duty, please list all with corresponding years of service starting
with the most recent. Use additional pages if necessary.)
Any break in civilian service? ___YES ___NO
When was break? ____________
FEDERAL DEPARTMENT EMPLOYED BY: (i.e. Dept. of Defense, Justice, Homeland Security, etc.)
_____________________________________
FEDERAL AGENCY: (i.e. Border Patrol, Immigration, Customs,
Army, Secret Service, etc.)
_____________________________________
Place of Employment: _________________________________________________
Address: ______________________________________
______________________________________
Beginning Date of Service: _________________ Ending Date: _____________________
(if current, please indicate)