1. Are you currently or were you ever a Hooters employee?

Are you currently or were you ever a Hooters employee? Yes, currently employed.

No, not now, but formerly employed.

No, never (exit survey)

2. Please give us your name and address so that we can follow up with you regarding the case.

Please give us your name and address so that we can follow up with you regarding the case. Name
Address
Address 2
City/Town
State
ZIP/Postal Code
Email
Phone

3. At which Hooters do you or did you work? If you did not work at any of the locations below please check 'Other.'

At which Hooters do you or did you work? If you did not work at any of the locations below please check 'Other.' Dublin Hooters

Fremont Hooters

SF Hooters

Campbell Hooters

Sacramento

Natomas

Rancho Cordova

Fresno

Bakersfield

Anaheim

Burbank

Costa Mesa

Hollywood

Gaslamp (San Diego)

lake Forest

Long Beach

Mission Valley

Oceanside

Ontario

Pacific Beach

Pasadena

Rancho Bernardo

Riverside (Moreno Valley)

Santa Monica

West Covina

Temecula

Other (please specify)

4. Please give dates you were or are employed.

	MM		DD		YYYY
from	Please give dates you were or are employed. from Month	/	Day	/	Year
to	to Month	/	Day	/	Year

5. Do you think you have been a victim of wage and hour violations? Check all that apply.

Do you think you have been a victim of wage and hour violations? Check all that apply. Not provided the opportunity to take 10 minute break(s) every four (4) hours

Forced to take thirty (30) minute meal break at or near beginning of shift

Had to pay for some or all of my uniforms

Had to pay for customer walkouts or cash shortages

Did not receive pay when sent home at beginning of shift

Worked at off-site promotions and did not get paid or paid in cash

Share of tips taken from your gross sales of Hooters' merchandise

Paid in cash for other "work"

Did not receive final check on last day of work

No, none of the above

Other (please specify)

6. Regarding the wage and hour violations you checked above, provide as much detail as possible: where, when, what happened, and if there were any witnesses? Please give details.

Regarding the wage and hour violations you checked above, provide as much detail as possible: where, when, what happened, and if there were any witnesses? Please give details.

7. Do you have any documents to help prove your claims?

Do you have any documents to help prove your claims? Wage stubs

Receipts (credit card, ATM, other) for purchase of uniforms

Calendars, emails, text messages or other documents to support your claims

Pictures of you working at or in a Hooters' uniform

Other

8. Any other comments, such as names of managers you worked with, other problems at work, etc.?

Any other comments, such as names of managers you worked with, other problems at work, etc.?

9. Can you provide other information to help the lawsuit? Again, this is not a client solicitation. Your information will be provided directly to Burt Boltuch.

Can you provide other information to help the lawsuit? Again, this is not a client solicitation. Your information will be provided directly to Burt Boltuch. No. Thank you.

Yes. Your information will be given to Burton F. Boltuch, attorney for the women who have filed the lawsuit.

10. Can you suggest others for us to contact?

Can you suggest others for us to contact? Name
Email
Cell Phone