Employment Intake Form LinkedInThis field is for validation purposes and should be left unchanged.Name First Last PhoneEmail Are you still employed?*(Please select)YesNoWere you a member of a union?*(Please select)YesNoDid you work for a government entity?*(Please select)YesNoWhen were you terminated? MM slash DD slash YYYY Who was your employer?What was the reason your employer terminated you?Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Language Preference*(Please select)EnglishSpanishChineseKoreanTagalogVietnameseArmenianFarsiArabicCambodianHindiHmongJapanesePunjabRussianThaiRepresentative Name*