CALIFORNIA'S PRIVATE ATTORNEYS GENERAL ACT

Your information

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone Number *

Job Title *

Date of Hire *

How You Were Paid *

Hourly Salary Commission

How Much You Made Per Week *

Duties and Responsibilities *

claims and issues

Please Check All Box That Are Applicable *

I did not get paid for all of my time My employer did not keep track of my time accurately My paystubs are inaccurate or lack information I did not receive uninterrupted meal and/or rest breaks Other

If "Other," Please Explain *

If NO Longer Employed (please select one) *

Last Day of Work (if applicable) *

Employer information

Name *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Number of Employees in California *

Number of Affected Employees in California *

Additional Comments *

Submit