Boat Supply Workers - created by phpFormGenerator

Full Name: *

Date of Birth: *

Address: *

City: *

State: *

Zip Code: *

Home Phone:

Work Phone:

Cell Phone:

Alternate Phone:

Best number to reach you:

Best time to reach you:

Email address:

Are you:

Do you have any minor children or other dependents:YesNo

Do you work on a supply boat for deepwater oil rigs or have you worked on a supply boat for deepwater oil rigs since April 1, 2010?YesNo

What was your job title:

Name of Employer(s):

Employer’s telephone Number:

Name of Human Resources Director or Supervisor at Employment:

Date of last day you worked:

Have you suffered a financial hardship due to the drilling moratorium resulting from the BP Oil Spill:YesNo

Have your work hours been reduced:YesNo

Have you received a furlough letter from your employer?YesNo

Are you receiving unemployment benefits from the state or federal government?YesNo

If yes, provide the dollar amount and frequency of the payments, including the date of the first payment:

Have you found other employment?YesNo

If you have found other employment are you making more or less than before the drilling moratorium:MoreLessSame

2009 Tax Returns with supporting W-2 Form(s):YesNo

2010 W-2 Form(s):YesNo

Pay history from May 6, 2010 to the present:YesNo

Copy of letter from employer regarding furlough or reduced hours:YesNo

Please list the deepwater rigs you supplied:

How did you hear about our firm?

Have you contacted another attorney or signed a contract with another attorney?YesNo

Type the following: