Am I Eligible? Thank you for registering your expression of interest in the merivale class action. Please fill out the short questionnaire below. Step 1 of 3 33% Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Phone*Please enter with country code format, for example if entering a mobile number please enter it as +61xxxxxxxxx by dropping the first 0 of the mobile number or area code.Email* Enter Email Confirm Email Address* Street Address City State / Province / Region Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date Of Birth* Date Format: DD slash MM slash YYYY Were you employed by M.R.V.L Investments Pty Ltd (Merivale) to work in a hospitality or restaurant role within the last 6 years?*YesNo During your employment with Merivale what positions did you work in?*Were any of these positions at Merivale salaried?*YesNoDuring your employment with Merivale were you paid for every hour that you worked?*YesNoDuring your employment with Merivale do you believe that every hour you worked was captured via the “thumb in/thumb out” system?*YesNoIf no, please detail*During your employment Merivale were you paid for attending compulsory training and/or meetings?*YesNoDuring your employment with Merivale do you recall ever being told that you were paid above Award wages?*YesNoIf yes, please enter the name or title of the person who communicated this to you and when*During your employment with Merivale were you ever reprimanded for refusing to work a shift?*YesNoIf yes, please detail each occurance*During your time at Merivale, how many venues did you work at?*12345678910Only include venues you worked at during the past 10 yearsWhich venues did you work at?*Little FelixLotusBar TopaTotti’sHotel CentennialBert’s Bar & BrasserieFred’sThe CollaroyMr. WongCharlie Parker’sQueen Chow EnmoreQueen Chow ManlyThe NewportCoogee PavillionFelixest.Ms. G’sThe PaddingtonPalmer & Co.J&MThe Smelly GoatPool ClubAsh St. CellarCoogee Pavillion RooftophemmesphereQueens HotelPalingssushi eLorraine’s PatisserieuccelloZebra BarHotel Centennial High Table3 WeedsThe RoyalEstablishmentivyThe BeresfordThe Chicken ShopYork 75Wynyard HotelThe Royal GeorgeThe Grand HotelTank Stream BarTennyson HotelEstablishment GardenHotel CBDEstablishment Bar30 KnotsAngel HotelEl Loco at Slip InnEl Loco at ExcelsiorWork in ProgressThe Bottle Shop| BondiThe Bottle Shop| EnmoreThe Bottle Shop| Vic on the ParkThe Bottle Shop| NewportThe Bottle Shop| CBDThe Vic on the ParkPalings FlowersRNB Fridays Club (at ivy)Rogue (at Establishment)Ministry of Sound Club (at ivy)POOF DOOF (at ivy)Marco Polo (at ivy)Start Date (approx)* Date Format: DD slash MM slash YYYY End Date (approx)* Date Format: DD slash MM slash YYYY Which venues did you work at? (2)*Little FelixLotusBar TopaTotti’sHotel CentennialBert’s Bar & BrasserieFred’sThe CollaroyMr. WongCharlie Parker’sQueen Chow EnmoreQueen Chow ManlyThe NewportCoogee PavillionFelixest.Ms. G’sThe PaddingtonPalmer & Co.J&MThe Smelly GoatPool ClubAsh St. CellarCoogee Pavillion RooftophemmesphereQueens HotelPalingssushi eLorraine’s PatisserieuccelloZebra BarHotel Centennial High Table3 WeedsThe RoyalEstablishmentivyThe BeresfordThe Chicken ShopYork 75Wynyard HotelThe Royal GeorgeThe Grand HotelTank Stream BarTennyson HotelEstablishment GardenHotel CBDEstablishment Bar30 KnotsAngel HotelEl Loco at Slip InnEl Loco at ExcelsiorWork in ProgressThe Bottle Shop| BondiThe Bottle Shop| EnmoreThe Bottle Shop| Vic on the ParkThe Bottle Shop| NewportThe Bottle Shop| CBDThe Vic on the ParkPalings FlowersRNB Fridays Club (at ivy)Rogue (at Establishment)Ministry of Sound Club (at ivy)POOF DOOF (at ivy)Marco Polo (at ivy)Start Date (approx)* Date Format: DD slash MM slash YYYY End Date (approx)* Date Format: DD slash MM slash YYYY Which venues did you work at? (3)*Little FelixLotusBar TopaTotti’sHotel CentennialBert’s Bar & BrasserieFred’sThe CollaroyMr. WongCharlie Parker’sQueen Chow EnmoreQueen Chow ManlyThe NewportCoogee PavillionFelixest.Ms. G’sThe PaddingtonPalmer & Co.J&MThe Smelly GoatPool ClubAsh St. CellarCoogee Pavillion RooftophemmesphereQueens HotelPalingssushi eLorraine’s PatisserieuccelloZebra BarHotel Centennial High Table3 WeedsThe RoyalEstablishmentivyThe BeresfordThe Chicken ShopYork 75Wynyard HotelThe Royal GeorgeThe Grand HotelTank Stream BarTennyson HotelEstablishment GardenHotel CBDEstablishment Bar30 KnotsAngel HotelEl Loco at Slip InnEl Loco at ExcelsiorWork in ProgressThe Bottle Shop| BondiThe Bottle Shop| EnmoreThe Bottle Shop| Vic on the ParkThe Bottle Shop| NewportThe Bottle Shop| CBDThe Vic on the ParkPalings FlowersRNB Fridays Club (at ivy)Rogue (at Establishment)Ministry of Sound Club (at ivy)POOF DOOF (at ivy)Marco Polo (at ivy)Start Date (approx)* Date Format: DD slash MM slash YYYY End Date (approx)* Date Format: DD slash MM slash YYYY Which venues did you work at? (4)*Little FelixLotusBar TopaTotti’sHotel CentennialBert’s Bar & BrasserieFred’sThe CollaroyMr. WongCharlie Parker’sQueen Chow EnmoreQueen Chow ManlyThe NewportCoogee PavillionFelixest.Ms. G’sThe PaddingtonPalmer & Co.J&MThe Smelly GoatPool ClubAsh St. CellarCoogee Pavillion RooftophemmesphereQueens HotelPalingssushi eLorraine’s PatisserieuccelloZebra BarHotel Centennial High Table3 WeedsThe RoyalEstablishmentivyThe BeresfordThe Chicken ShopYork 75Wynyard HotelThe Royal GeorgeThe Grand HotelTank Stream BarTennyson HotelEstablishment GardenHotel CBDEstablishment Bar30 KnotsAngel HotelEl Loco at Slip InnEl Loco at ExcelsiorWork in ProgressThe Bottle Shop| BondiThe Bottle Shop| EnmoreThe Bottle Shop| Vic on the ParkThe Bottle Shop| NewportThe Bottle Shop| CBDThe Vic on the ParkPalings FlowersRNB Fridays Club (at ivy)Rogue (at Establishment)Ministry of Sound Club (at ivy)POOF DOOF (at ivy)Marco Polo (at ivy)Start Date (approx)* Date Format: DD slash MM slash YYYY End Date (approx)* Date Format: DD slash MM slash YYYY Which venues did you work at? (5)*Little FelixLotusBar TopaTotti’sHotel CentennialBert’s Bar & BrasserieFred’sThe CollaroyMr. WongCharlie Parker’sQueen Chow EnmoreQueen Chow ManlyThe NewportCoogee PavillionFelixest.Ms. G’sThe PaddingtonPalmer & Co.J&MThe Smelly GoatPool ClubAsh St. CellarCoogee Pavillion RooftophemmesphereQueens HotelPalingssushi eLorraine’s PatisserieuccelloZebra BarHotel Centennial High Table3 WeedsThe RoyalEstablishmentivyThe BeresfordThe Chicken ShopYork 75Wynyard HotelThe Royal GeorgeThe Grand HotelTank Stream BarTennyson HotelEstablishment GardenHotel CBDEstablishment Bar30 KnotsAngel HotelEl Loco at Slip InnEl Loco at ExcelsiorWork in ProgressThe Bottle Shop| BondiThe Bottle Shop| EnmoreThe Bottle Shop| Vic on the ParkThe Bottle Shop| NewportThe Bottle Shop| CBDThe Vic on the ParkPalings FlowersRNB Fridays Club (at ivy)Rogue (at Establishment)Ministry of Sound Club (at ivy)POOF DOOF (at ivy)Marco Polo (at ivy)Start Date (approx)* Date Format: DD slash MM slash YYYY End Date (approx)* Date Format: DD slash MM slash YYYY Which venues did you work at? (6)*Little FelixLotusBar TopaTotti’sHotel CentennialBert’s Bar & BrasserieFred’sThe CollaroyMr. WongCharlie Parker’sQueen Chow EnmoreQueen Chow ManlyThe NewportCoogee PavillionFelixest.Ms. G’sThe PaddingtonPalmer & Co.J&MThe Smelly GoatPool ClubAsh St. CellarCoogee Pavillion RooftophemmesphereQueens HotelPalingssushi eLorraine’s PatisserieuccelloZebra BarHotel Centennial High Table3 WeedsThe RoyalEstablishmentivyThe BeresfordThe Chicken ShopYork 75Wynyard HotelThe Royal GeorgeThe Grand HotelTank Stream BarTennyson HotelEstablishment GardenHotel CBDEstablishment Bar30 KnotsAngel HotelEl Loco at Slip InnEl Loco at ExcelsiorWork in ProgressThe Bottle Shop| BondiThe Bottle Shop| EnmoreThe Bottle Shop| Vic on the ParkThe Bottle Shop| NewportThe Bottle Shop| CBDThe Vic on the ParkPalings FlowersRNB Fridays Club (at ivy)Rogue (at Establishment)Ministry of Sound Club (at ivy)POOF DOOF (at ivy)Marco Polo (at ivy)Start Date (approx)* Date Format: DD slash MM slash YYYY End Date (approx)* Date Format: DD slash MM slash YYYY Which venues did you work at? (7)*Little FelixLotusBar TopaTotti’sHotel CentennialBert’s Bar & BrasserieFred’sThe CollaroyMr. WongCharlie Parker’sQueen Chow EnmoreQueen Chow ManlyThe NewportCoogee PavillionFelixest.Ms. G’sThe PaddingtonPalmer & Co.J&MThe Smelly GoatPool ClubAsh St. CellarCoogee Pavillion RooftophemmesphereQueens HotelPalingssushi eLorraine’s PatisserieuccelloZebra BarHotel Centennial High Table3 WeedsThe RoyalEstablishmentivyThe BeresfordThe Chicken ShopYork 75Wynyard HotelThe Royal GeorgeThe Grand HotelTank Stream BarTennyson HotelEstablishment GardenHotel CBDEstablishment Bar30 KnotsAngel HotelEl Loco at Slip InnEl Loco at ExcelsiorWork in ProgressThe Bottle Shop| BondiThe Bottle Shop| EnmoreThe Bottle Shop| Vic on the ParkThe Bottle Shop| NewportThe Bottle Shop| CBDThe Vic on the ParkPalings FlowersRNB Fridays Club (at ivy)Rogue (at Establishment)Ministry of Sound Club (at ivy)POOF DOOF (at ivy)Marco Polo (at ivy)Start Date (approx)* Date Format: DD slash MM slash YYYY End Date (approx)* Date Format: DD slash MM slash YYYY Which venues did you work at? (8)*Little FelixLotusBar TopaTotti’sHotel CentennialBert’s Bar & BrasserieFred’sThe CollaroyMr. WongCharlie Parker’sQueen Chow EnmoreQueen Chow ManlyThe NewportCoogee PavillionFelixest.Ms. G’sThe PaddingtonPalmer & Co.J&MThe Smelly GoatPool ClubAsh St. CellarCoogee Pavillion RooftophemmesphereQueens HotelPalingssushi eLorraine’s PatisserieuccelloZebra BarHotel Centennial High Table3 WeedsThe RoyalEstablishmentivyThe BeresfordThe Chicken ShopYork 75Wynyard HotelThe Royal GeorgeThe Grand HotelTank Stream BarTennyson HotelEstablishment GardenHotel CBDEstablishment Bar30 KnotsAngel HotelEl Loco at Slip InnEl Loco at ExcelsiorWork in ProgressThe Bottle Shop| BondiThe Bottle Shop| EnmoreThe Bottle Shop| Vic on the ParkThe Bottle Shop| NewportThe Bottle Shop| CBDThe Vic on the ParkPalings FlowersRNB Fridays Club (at ivy)Rogue (at Establishment)Ministry of Sound Club (at ivy)POOF DOOF (at ivy)Marco Polo (at ivy)Start Date (approx)* Date Format: DD slash MM slash YYYY End Date (approx)* Date Format: DD slash MM slash YYYY Which venues did you work at? (9)*Little FelixLotusBar TopaTotti’sHotel CentennialBert’s Bar & BrasserieFred’sThe CollaroyMr. WongCharlie Parker’sQueen Chow EnmoreQueen Chow ManlyThe NewportCoogee PavillionFelixest.Ms. G’sThe PaddingtonPalmer & Co.J&MThe Smelly GoatPool ClubAsh St. CellarCoogee Pavillion RooftophemmesphereQueens HotelPalingssushi eLorraine’s PatisserieuccelloZebra BarHotel Centennial High Table3 WeedsThe RoyalEstablishmentivyThe BeresfordThe Chicken ShopYork 75Wynyard HotelThe Royal GeorgeThe Grand HotelTank Stream BarTennyson HotelEstablishment GardenHotel CBDEstablishment Bar30 KnotsAngel HotelEl Loco at Slip InnEl Loco at ExcelsiorWork in ProgressThe Bottle Shop| BondiThe Bottle Shop| EnmoreThe Bottle Shop| Vic on the ParkThe Bottle Shop| NewportThe Bottle Shop| CBDThe Vic on the ParkPalings FlowersRNB Fridays Club (at ivy)Rogue (at Establishment)Ministry of Sound Club (at ivy)POOF DOOF (at ivy)Marco Polo (at ivy)Start Date (approx)* Date Format: DD slash MM slash YYYY End Date (approx)* Date Format: DD slash MM slash YYYY Which venues did you work at? (10)*Little FelixLotusBar TopaTotti’sHotel CentennialBert’s Bar & BrasserieFred’sThe CollaroyMr. WongCharlie Parker’sQueen Chow EnmoreQueen Chow ManlyThe NewportCoogee PavillionFelixest.Ms. G’sThe PaddingtonPalmer & Co.J&MThe Smelly GoatPool ClubAsh St. CellarCoogee Pavillion RooftophemmesphereQueens HotelPalingssushi eLorraine’s PatisserieuccelloZebra BarHotel Centennial High Table3 WeedsThe RoyalEstablishmentivyThe BeresfordThe Chicken ShopYork 75Wynyard HotelThe Royal GeorgeThe Grand HotelTank Stream BarTennyson HotelEstablishment GardenHotel CBDEstablishment Bar30 KnotsAngel HotelEl Loco at Slip InnEl Loco at ExcelsiorWork in ProgressThe Bottle Shop| BondiThe Bottle Shop| EnmoreThe Bottle Shop| Vic on the ParkThe Bottle Shop| NewportThe Bottle Shop| CBDThe Vic on the ParkPalings FlowersRNB Fridays Club (at ivy)Rogue (at Establishment)Ministry of Sound Club (at ivy)POOF DOOF (at ivy)Marco Polo (at ivy)Start Date (approx)* Date Format: DD slash MM slash YYYY End Date (approx)* Date Format: DD slash MM slash YYYY Disclosure Letter3> By signing below and submitting this form you: reasonably believe that you will be eligible to participate in the action; warrant that; the information you have provided is true and correct; and you will not sign-up or register using any false or misleading details; hereby execute and agree to be bound by and comply with the terms of the; Retainer Agreement and consent to us entering the information you have provided to us into those documents have been given the opportunity to obtain independent legal advice as to the nature and effect of the Retainer Agreement and you agree to be bound and comply with the terms of our Retainer Agreement; after obtaining, and in reliance on such independent legal advice; or having elected not to obtain independent legal advice; and you have read and understood the nature and effect of our Retainer; and you do not require any explanation or advice in relation to those documents; consent and authorise us to use the information provided to assess whether or not you may be eligible to participate in the action; and consent to receive further communications from us regarding any continued participation in the action. Signature*Consent* I agree to the terms and conditions.By submitting this form you: Reasonably believe that you will be eligible to participate in the action; Warrant that: the information you have provided is true and correct; and you will not sign-up or register using any false or misleading details; Consent and authorise us to use the information provided to assess whether or not you may be eligible to participate in the action; and Consent to receive further communications from us regarding any continued participation in the action* I understand that the retainer and the disclosure letter are confidential documents. I understand that I am not permitted to share these documents or the information contained therein with any third party or for any purpose other than participating in the proposed proceedings. If you would prefer to sign a hard copy of this agreement, please print out a copy of the Retainer Agreement, complete the Claimant Details in the document, sign it, and then scan it as a PDF and email it to: merivale@aderolaw.com.au