1. Your Name

First Name

Last Name

2. Your Email

3. Your Phone

Country

(###)

###

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4. What State or Territory do you live in?

5. How long ago were you dismissed from your job?

6. How long were you employed there for?

7. What was the size of the business you worked for?

1-14 employees or 15+ employees, including yourself and any casual workers

8. What was your working arrangement?

full-time, part-time, casual etc

9. Further comments

If there is anything else you would like us to know prior to making contact with you, or if you have any questions or issues you would like to raise