Whistleblower and are seeking GAP's assistance, Sylvia Lydia Morelos

Wufoo

GAP Intake Application

If you are a whistleblower and are seeking GAP's assistance, or if you are interested in blowing the whistle on an issue of public concern, please fill out our intake application in order to initiate a review of your case by counsel.

All applications will remain confidential.

GAP's whistleblower cases currently include the following program areas:

a) Corporate & Financial Accountability
b) Environment
c) Food integrity
d) Government Employees
e) Homeland Security & Human Rights
f) International Reform
g) Legislation
h) Litigation
i) Public Health

While the breadth of topics that GAP handles has no limits, over the past 30 years GAP's clients have led the organization to develop program areas which demand GAP's constant attention. However, we will consider exceptional whistleblower cases outside our program areas.

GAP seeks to focus on widespread, systemic issues and problems within the aforementioned program areas. We do not handle small-scale cases or individual problems unless they are indicative of a large-scale problem. We also do not handle EEO issues (those dealing with non-whistleblower related discrimination, or discrimination based on age, gender, religion or race) unless they are brought in conjunction with a whistleblower case. However, we do accept Qui Tam cases.

All of those interested in working with GAP or obtaining GAP's assistance must fill out and submit the below form for consideration. Please note that this does not constitute an offer of services or representation. A completed form will allow us to properly review your potential case and make a determination as to whether or not we might be able to help. You may expect to hear back from us within approximately three weeks.

Please do not send GAP any documents or correspondence in addition to your intake form. We will let you know if we require additional information.

**Please note that we no longer utilize the "intake@whistleblower" email address for intake applications. For further queries, please contact:

Intake Coordinator
Government Accountability Project
1612 K Street, N.W., Suite #1100
Washington, D.C 20006
202.457.0034, ext. 143

• DISCLAIMER:
  
  It is important for you to understand that your application to us, or communicating with us about your application, does not mean that we are representing you. Indeed, because our lawyers are governed by licensing authorities, we must inform you that GAP lawyers are not representing you unless and until you receive written notification of that, and have signed a retainer agreement. Until such point your application to GAP is simply under consideration, and should we request more information or documents from you, this is only a part of the application process.
  
  Please be advised that GAP cannot guarantee prompt review or a decision regarding your intake application. It is advisable that you understand the deadlines and/or statute of limitations associated with your case. GAP is not responsible for alerting you to such limitation periods during the application process.

• Before You Start... *

  I have read, understood, acknowledge and agree to the conditions and terms mentioned in the "Disclaimer" above.

• I. Contact Information

  (We do not recommend using any work contact information for the purposes of this application)
• Name * First Last
• Address
  Street Address Address Line 2 City State / Province / Region Postal / Zip Code United States United Kingdom Australia Canada France New Zealand India Brazil ---- Afghanistan Åland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Democratic Republic of the Congo Republic of the Congo Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faroe Islands Fiji Finland Gabon Gambia Georgia Germany Ghana Gibraltar Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles Nicaragua Niger Nigeria Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Yemen Zambia Zimbabwe Country
• Email *
• Home Phone ### - ### - ####
• Cell Phone ### - ### - ####
• Where did you hear about GAP?

  Internet ResearchNews Report/Media coverageGovernment OfficialNonprofit OrganizationFriend/Co-workerOther

• II. Whistleblowing Activity

• 1. Please check the program areas that apply to your whistleblowing activity.

  Corporate AccountabilityEnvironmentFood IntegrityGovernment EmployeesHomeland Security & Human RightsInternational Reform ( World Bank, United Nations, etc.,)LegislationLitigationPublic HealthOther
• 2. Have you disclosed information that evidences:

  a violation of any law, rule or regulationgross mismanagementan abuse of authoritysubstantial and specific danger to public health or safetyother wrong-doingdon't know
• 3. If you have disclosed information, please provide the name, title and office of the person(s) to whom the disclosure has been made, date disclosure was made and in what form (verbal, confidential memo, official complaint etc.,)?
• 4. Summarize in one page or less the disclosure and/or abuse, in chronological order if feasible:
• 5. What, if any adverse employment actions (e.g., suspension, retaliation and/or termination) have occurred against you due to your whistleblowing activity? Please include dates.

• III. Employer Information

• 1. Name of company or government agency involved in whistleblower claim.
• 2. Are you an employee/contractor (either current or former) of this company or agency?

  Yes No
• 3. If a company or corporation, is it publicly traded?

  Yes No
• If yes, please describe:
• 4. If a government agency, is it

  FederalStateLocal
• 5. If you are/were a federal or military employee what is your GS or other ranking?
• 6. Do/did you have union membership?
• If yes, please describe:
• 7 a) Job title at the time of whistleblowing activity:
• b) Briefly describe your job duties:
• c) What is/was the length of time you were employed at the company or government agency?
• 8. Current Employer/Job Status:

• IV. Legal History

• 1. Who have you contacted outside your company or government agency for assistance?
• 2. What are your goals in this matter?
• 3. Do you have, or have you previously had, an attorney representing you on this case?
• 4. Are you currently involved in any ongoing legal or administrative proceedings?
• 5. Please briefly list by date and provide a short explanation describing any employment-related grievance, complaint, or lawsuit you have submitted or filed in the last 5 years.
• 6. What services do you seek from GAP (such as legal representation, media advocacy, advice, etc.,)?
• 7a. Are you seeking advice or assistance ONLY for the purpose of making a DISCLOSURE? *

  YesNoUnsure
• 7b. If you are seeking LEGAL REPRESENTATION, can you afford GAP's standard non-profit attorney fee for services of approximately $85-$175 per hour? In addition, are you able to pay the expenses associated with litigation, such as depositions, print materials or travel expenses, if necessary?Please note your ability to pay is not the primary factor GAP considers in our decision to represent you. However, we do expect people with means and an income to pay toward their representation as well as expenses. Our public interest rates are a fraction of what private attorneys charge. In addition, we do not charge initial consultation fees for an inquiry regarding representation. *

  Yes No
• Do Not Fill This Out