Employment Information Form

Full Name(required)

Email Address(required)

Phone Number(required)

Name of the Company you work(ed) for?(required)

Dates of Employment (eg. 2016-2017)(required)

Method(s) of Compensation (eg. $18/hour, $40,000 salary)(required)

Average hours worked per week (eg. 40, 50, 60)(required)

Job Title(required)

Job duties performed during your employment (eg. answered calls, manual labor, etc.)(required)

Names and contact information of others who may be eligible to join your potential claim?

Any Additional Information?