Stellar | Registration Form

COMPLETE THIS FORM IF YOU WISH TO REGISTER YOUR INTEREST IN MAKING A CLAIM THROUGH THE STELLAR CLASS ACTION

1. FORM COMPLETION

The person completing this form is:(Required)

a group member

someone else, completing on behalf of a group member

2. PERSONAL DETAILS OF PERSON COMPLETING THIS FORM

Name(Required)

Title First Name/s Last name

Email Address(Required)

3. GROUP MEMBER DETAILS

Name of Group Member(Required)

Title First Name/s Last name

Date of Birth(Required)

Email Address(Required)

Phone Number(Required)

Alternate Phone Number

Postal Address(Required)

Street Address Suburb/Town State / Province / Region ZIP / Postal Code Country

4. DOCUMENTARY EVIDENCE

Date your employment commenced with the Respondent?

List of positions held during the course of your employment with the Respondent?

What hours do you say that you were required to, and did work, during your employment with the Respondent? If you have documentary records of this, please attach that material to this form.

Date your employment with the Respondent ended (if applicable)?

Insert any supporting documents you want the parties to the class action to take into account.

Max. file size: 8 MB.

5. EXECUTION

Date(Required)

Signature

Signed by, or on behalf of and with the authority of, the Group Member (as specified above)

Print Name