Lovisa | Registration of Interest

Register Interest Lovisa

The person completing this form is

An eligible Group Member

Someone else, completing on behalf of an eligible Group Member

Personal details of person completing this form

Name(Required)

Prefix First Last

Date of Birth(Required)

Email(Required)

2. GROUP MEMBER DETAIL

Personal details of individual

Name(Required)

Prefix First Last

Email(Required)

Phone(Required)

Alternative Phone

Address(Required)

Street Address Surburb/town State / Province / Region ZIP / Postal Code Country

3. DOCUMENTARY EVIDENCE

You are required to take reasonable steps to provide the following information. Please attach further sheets of paper if you need more space. Please also attach any supporting documents you want the parties to the class action to take into account. However, failure to do so will not invalidate your registration

What date did your employment commence with the Respondent?(Required)

Please list the positions you held during the course of your employment with the Respondent.(Required)

Were you employed on a fulltime or part-time basis? If you worked in both a part-time and full-time basis at some stage throughout your employment, please list both and include the relevant dates.(Required)

What date did your employment with the Respondent end (if applicable)?

I have attached documentary evidence in support of the information herein(Required)

Yes

No

File(Required)

Max. file size: 8 MB.

4. EXECUTION

Date of form submission(Required)

Signed by, or on behalf of and with the authority of, the Group Member (as specified above)(Required)

Print Name(Required)

First Last