ESGR Forms

ONLINE FORMS

ESGR USERRA Support Request Form 100

This form is intended for Guard & Reserve members who are experiencing civilian employment problems related to military service. This form can also be used to request information and ask questions related to the Uniformed Services Employment and Reemployment Rights Act (USERRA).

ESGR is an agency of the Department of Defense and organized as part of the Office of the Assistant Secretary of Defense for Reserve Affairs. ESGR’s Ombudsman Services Program was instituted to provide a means by which disputes arising under the Uniformed Services Employment and Reemployment Rights Act (USERRA) can be informally mediated between employers and their Guard and Reserve employees. Disputes between employers and employees are resolved through the efforts of ESGR’s Volunteer Ombudsmen in all 50 states, 4 territories and Europe. The communications made by parties during informal mediation are protected by the Administrative Dispute Resolution Act.

Before you submit this complaint, please familiarize yourself with the USERRA law. For more information, please check the USERRA section.

If you believe your rights under USERRA have been violated by your employer, you can call 1-800-336-4590 option (1) to speak with an ESGR representative or you may fill out the online ESGR Form 100 and have your complaint reviewed. An ESGR representative will contact you within 48 hours of the first business day after receiving your request.

An asterisk (*) indicates a required field in the page

Section I: Service Member Information
	*	First Name:
		Middle Name:
	*	Last Name:
		Address:
		City:
		State:
		ZIP Code:
	*	Home Phone:
		Work Phone:
	*	E-Mail:
Section II: Uniformed Service Information
		Serve(d) in:	ARNG ANG USAR USAFR USMCR USNR USCGR Army Navy Marine Coast Guard Public Health Service National Disaster Medical System Other (Explain in "Comments")
		Military Pay Grade:
		Name of Unit:
		Unit Address:
		Unit Phone:
		Unit POC:
		Type of Discharge or Separation:	Honorable Conditions Entry Level Uncharacterized Medical Other than Honorable Conditions Other (Explain in "Comments") Not Applicable
Section III: Employer Information
		Employer or Prospective Employer’s Name:
		Address:
		City:
		State:
		ZIP Code:
		Principal Employer Contact (PEC):
		PEC Name/Title:
		PEC Phone:
Section IV: Privacy Statement
	"Before you provide any information, ESGR Ombudsman Services must advise you that the information you will provide pursuant to the Uniformed Services Employment and Reemployment Rights Act is for the principal purpose of assisting you in providing informal mediation efforts to resolve potential issues involving your rights under the Act. Any information collected may be disclosed to a Federal, States, and local governmental agency in furtherance of such mediation efforts and to the Department of Labor and the Department of Justice in connection with any litigation stemming from potential violations of the Act. Disclosure of the information is voluntary. However, failure to furnish the information may hinder or preclude appropriate assistance being provided to you on your specific claim or concern."
	*	Initials:
		Date:
		Have you officially engaged the Department of Labor or hired a private attorney? Yes No
		Do you give us permission to speak with your employer? Yes No
		Is this a request for information only? Yes No
		How did you find out about ESGR?
Section V: Explain your claim in detail (Who, What, When, Where and Why)
		Comments: (3000 chars.)