Rebel Class Action Registration Form

Name(Required)

Prefix First Last

Remain Anonymous(Required)

Yes

No

Email Address(Required)

Phone Number(Required)

Date of Birth(Required)

Address(Required)

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

Position(s) Held(Required)

(e.g. Store Manager, Department Manager)

Employment Type

Full Time

Part Time

Other

Are you still employed with Rebel?(Required)

Yes

No

Employment Start Date(Required)

Employment End Date

Additional Relevant Information (optional)

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