Merivale | Survey Step 1 of 2 50% PERSONAL DETAILSName(Required) First Last Address(Required) Street Address City State Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth(Required) DD slash MM slash YYYY Email(Required)Enter the email address you used to sign up for the class action. Phone(Required)Please add your country code (e.g. 61) to the start of your mobile number.Were you employed by M.R.V.L. Investments Pty Ltd (Merivale) to work in a hospitality or restaurant role anytime from 25 December 2013 to 25 December 2019?(Required)Yes / NoYesNoEmployment Type(Required)Select the employment type(s) that applied to you during the period between December 2013 and December 2019 Full-Time Permanent Part-Time Permanent Casual Employee ID (Optional)(Required)If you have more than one ID number, please separate them with a comma. What position(s) did you work?(Required) Which venues did you work at?(Required) Start Date(Required) MM slash DD slash YYYY End Date(Required) MM slash DD slash YYYY Contract(s) of Employment Upload (Optional) Drop files here or Select files Max. file size: 8 MB. Please share the below link with any past employees you think would be interested in registering their interest in the Merivale Class Action: https://www.aderolaw.com.au/class-actions/hospitality/merivale/survey/ By signing your name below, you confirm that: You are a group member in the Merivale class action, meaning you were employed by M.R.V.L. Investments Pty Ltd (Merivale) between 25 December 2013 to 24 December 2019 to work in a hospitality venue under the Merivale Employee Collective Agreement 2007 or the Hospitality (General) Industry Award 2010; You authorise Adero Law to request from Merivale, obtain, and store information related to your employment with Merivale for the purposes of the class action; and You consent to Adero Law providing the information recorded in this form to Merivale for the purposes of obtaining your employment records. HiddenConsent (optional) By signing your name below, you confirm that:1. You are a class member in the Merivale class action, meaning you were employed by M.R.V.L. Investments Pty Ltd (Merivale) between 25 December 2013 to 24 December 2019 to work in a hospitality venue under the Merivale Employee Collective Agreement 2007 or the Hospitality (General) Industry Award 2010; 2. You authorise Adero Law to request from Merivale, obtain, and store information related to your employment with Merivale for the purposes of calculating your individual claim, calculating an estimate of the potential loss for the class and/or assisting with the progression of the claim; and 3. You consent to Adero Law providing the information recorded in this form to Merivale for the purposes of obtaining your employment records.I HEREBY AUTHORISE AND DIRECT YOU to RELEASE to my lawyers, ADERO LAW of 3 Hobart Place, (PO Box 5121) City ACT 2601, copies of documents pertaining to my employment with M.R.V.L. Investments Pty Ltd, including records of my pay and time and attendance, and any other documentation and information requested by them.SIGNEDHiddenDATED DD slash MM slash YYYY
