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1. What is your name? (Required.)

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2. Which federal agency were you removed from? (Required.)

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3. What was your official work location (city and state)? (Required.)

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4. What was the date you were hired (e.g. entered on duty/EOD)? (Required.)

Date

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5. What was your position title? (Required.)

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6. Where you in the competitive or excepted service? (Required.)

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7. What is the effective date of your dismissal? (Required.)

Date

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8. Do you have written notification of your dismissal? (Required.)

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9. Upload written documentation of your dismissal, if available.

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10. What reason were you given for your dismissal? (Required.)

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11. Prior to your dismissal, had your supervisor discussed with you any concerns about your performance? (Required.)

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12. What is your NTEU chapter? (Required.)

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13. What is your personal email address? (Required.)

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14. What is your personal phone number? (Required.)

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