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For Employees Additional info
Name of your employer (at time of discriminatory act) :
Your position (at the time of the discriminatory act):
Are you still employed by this Company?:	Yes	No
Your annual salary with this Company is/was:
Have you resigned your employment?:	Yes	No
Were you dismissed?:	Yes	No
Have you secured new employment?:	Yes	No
If so on what annual salary:
Has the discrimination resulted in medical treatment?:	Yes	No
Are you able to fund legal action yourself?:	Yes	No