USERRA INTAKE FORM

Contact Information:

NAME: ___Mr. ___Ms. _____________________________________________

SOCIAL SECRUITY #: ____________________________________

DATE OF BIRTH: ____________________________________

HOME ADDRESS: ______________________________________________________

______________________________________________________

HOME PHONE: ____________________________________

OFFICE PHONE: ____________________________________

CELL PHONE: ____________________________________

EMAIL (home): ______________________________________________________

EMAIL (work): ______________________________________________________

How did you hear about our USERRA practice? _______________________________________

Are you currently deployed out of the United States? ___________________________

*Please complete Page 2

Military Service Information:

Beginning Date of Service: _______________________     Ending Date: __________________________

Which branch(es) did you serve in?    _________________________________________________
*Please include breakdown of dates served in each branch

Any year(s) you did not use any military leave?        ________________

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?   ______________________
            If Yes, did you sign a Settlement Agreement & please provide agency?   _____________________

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? ______________________________

Have you ever signed a Collective Bargaining Agreement? _____YES _____NO

FEDERAL DEPARTMENT(S) EMPLOYED BY: (i.e. Dept. of Defense, Dept. of Justice, Homeland Security, etc.)

_____________________________________________________________________________________

FEDERAL AGENCY(IES): (i.e. Border Patrol, Immigration, Customs, Army, Secret Service, etc.)

_____________________________________________________________________________________

Place(es) of Employment:   ______________________________________________________________

Address(es):    _________________________________________________________________________

                        _________________________________________________________________________

_________________________________________________________________________
*Please include breakdown of dates employed by each Agency

Beginning Date of Employment: ______________________ Ending Date: ______________________