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If you are currently employed by Wal-Mart or Sam's Club, or were employed by either in the past 180 or 300 days (depending on your state) and have experienced gender discrimination in denial of equal pay or denial of promotion to management, you may join us by filling out this form and we will contact you. If you last worked at Wal-Mart 300 days ago or longer, then it is too late for you to file an EEOC charge. In some states, you must have worked at Wal-Mart in the past 180 days, including AL, AR, GA, MS & NC. Please provide a telephone number and/or email address along with the requested information below so we will be able to contact you.

Contact Information:

Please provide all the names you've used on your employee records at Wal-Mart:

First Name: Last Name:
Maiden Name: Other Names:
What was your hire date at Wal-Mart? ,
What was your termination date at Wal-Mart,if any? ,
What was your highest position held at Wal-Mart?

If you currently work at Wal-Mart or left Wal-Mart within the last 180/300 days, what store location? (City and state is sufficient if you do not know the store no.)

Store NumberCityState

Please provide your most current address and contact information:

Current Address: City: State: Zip:
Home Phone: -- Cell Phone: --
Email Address:

In order to ensure that we can maintain contact with you and determine what claims you have as well as to access records that might support your claim, it would be very helpful to have your social security number. We understand that this is sensitive information, but it will be kept confidential and will not be viewed by anyone outside our legal team.

Social Security Number:


Do you have your own lawyer for issues related to Wal-Mart?

Have you filed a claim with the Equal Employment Opportunity Commission (EEOC) or a state fair employment agency regarding denial of equal pay or promotion into management at Wal-Mart?

If yes, when did you file it? ,

Have you filed a lawsuit regarding denial of equal pay or promotion into management at Wal-Mart?

If yes, when did you file it? ,

Our case is limited to pay and promotion into management issues. Tell us about your experiences concerning pay equity or denial of promotion into management in the space below.

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