Were you paid overtime for working for more than 40 hours per week?

Are you still employed with the company?

In No, when did you stop working for the company (Month/Year)?

Approximately, how many total hours per week did you usually work?

What was your rate of pay?
(ie: $15 / hour)

What was the title of your job?

How many employees work for the company now?

How many employees do you think are not receiving overtime pay?

Are there any other comments you have that we should consider that relate to your claim?

Full Name:

Email Address:

Address:

City:

State:

Zip:

Phone #

Alternate Phone #