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Not part of the class or want to contact us directly? Our Contact Information.

CONFIDENTIAL QUESTIONNAIRE FOR WAL-MART JANITORS

Please fill out this questionnaire so that we can determine if you may be included in the lawsuit. Any information you send us through this site is sent over a secure connection.

Name:

Date of Birth:

	/		/
(Month)		(Day)		(Year)

Address:

Address outside United States, if applicable:

Telephone (with area code):

Cell Telephone (with area code):

E-Mail:

Best time and way to contact you:

Country of Origin:

Do you speak English?

What language do you speak other than English?

When did you work as a janitor at Wal-Mart of Sam's Club?

Start date:

Do you still work as a janitor at Wal-Mart or Sam's Club?

If not, date you left Wal-Mart or Sam's Club:

Describe your work as a janitor at Wal-Mart or Sam's Club:

location(s)
supervisors
assistant manager(s)
store manager(s)

What, if any, maintenance company did you work for?

Name
address
telephone

How much were you paid?

How many hours a week did you work?

How many days a week did you work?

Did you receive overtime pay?

How were you paid:

If paid by check, were any checks you received returned for insufficient funds or because the account they were written on was closed?

If yes, how much is still owed to you?

Were you ever injured on the job?

If so, when?

Do you have children?

Did they ever accompany you to the work site?

Complaints about Wal-Mart or Sam's Club:

Is there anyone else you know whom we should contact?

Name
Address
telephone number

What has Wal-Mart or your maintenance contractor (or their managers and supervisors) said about this lawsuit?

Were you locked in the store during your shift?

Was there always a fire exit where you could escape in case of a fire?

If you were locked in, was a manager present who had a key to let you leave the store if necessary?

If no manager was present with a key, how were you let out of the store during or at the end of your shift?

How and when did you enter the United States?

Are you still in the United States?

If so, are you in deportation or any other proceedings with the U.S. Immigration and Customs Enforcement? (If so, please explain and provide copies of your Notice to Appear and any other documents.)

What questions can we answer for you?