Kmart Registration Form

Kmart Class Action Registration Form

Name(Required)

Prefix First Last

Date of Birth(Required)

Email Address(Required)

Phone Number(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Which store(s) do you currently work at, or have you worked at?(Required)

Position(s) Held(Required)

(e.g. Store Manager, Department Manager)

Employment Type

Full Time

Part Time

Other

Are you still employed with Kmart?(Required)

Yes

No

Employment Start Date(Required)

Employment End Date

Additional Relevant Information (optional)

(e.g. typical weekly hours worked, unpaid overtime, salary concerns)

Date

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