Name *

First Name

Last Name

Best Contact Phone No. *

(###)

###

####

1. During the last 90 days, have you had problems clocking in to work? *

Yes

No

2. During the last 90 days, have you had problems clocking out? *

Yes

No

3. During the last 90 days, do you believe the company has paid you correctly for all the hours that you have worked? *

Yes

No

4. During the last 90 days, has there ever been a time where you were unable to take your lunch (if you worked at least a 5-hour shift)? *

Yes

No

5. At most employers where workers are represented by Local 7, you are entitled to a paid 15-minute break if you work more than 2 hours, a second paid 15 minute break if you work more than 6 hours, and a third paid break after 10 hours. PLEASE NOTE: THIS only deals with your entitlement to paid breaks – and DOES NOT HAVE ANYTHING TO DO WITH THE TIMING OF YOUR BREAKS - During the last 90 days, has there ever been a time where you did not / could not take all of the breaks to which you are entitled? *

Yes

No

6. We are looking for individuals who have been working statutory overtime (more than 40 hours per week) on a regular basis during the past 12 months. Have you been doing this? If so, can the Legal Department contact you to investigate whether you have been paid correctly? *

Yes

No