The U.S. Equal Employment Opportunity Commission

APPLICANT'S CLAIM FORM

Note: This item is presented for informational purposes only. It is not a valid claim form. To obtain a claim form, please see http://www.eeocvwalmart.com/.

Instructions

Please answer every numbered question to establish your claim. When asked to "explain" your answer, please provide as much information as possible. Please feel free to write on the back of this form or to add additional pages as needed.

If you are unsure of any information, particularly dates, please approximate and write "approx."

If you do not know the answer to some question, please answer with "I don't know".

Please complete and enclose a Wal-Mart Job Application. Even if you are no longer interested in working at Wal-Mart, the completed job application will be reviewed to determine whether you were qualified under Wal-Mart's non-discriminatory hiring standards.

  1. Name:
  2. Address:
  3. Phone Number:
  4. Social Security Number:
  5. Did you complete and submit an application to work at a Wal-Mart Distribution Center at any time from 1994 through 1998?

    _____ Yes _____ No

Complete the remaining portion of this form only if you answered "Yes" to Question # 5

  1. At what Wal-Mart facility did you apply?
  2. When did you apply?
  3. What job or jobs did you apply for?
  4. Were you offered a job by Wal-Mart?
  5. If you were not offered a job at Wal-Mart, do you have any information or ideas about the reason you were not offered a job? Please explain.
  6. If you were interviewed, was your medical, physical, or mental condition discussed in any way? (for example: any discussion about physical limitations that would affect your ability to do the job; or, any history of medical conditions, including worker's compensation claims). Please explain.
  7. Do you think you were not offered a job by Wal-Mart based on information requested by Wal-Mart about your medical, physical, or mental condition during the application process? Please explain why you believe this?
  8. What was your home address at the time you applied for a job at a Wal-Mart Distribution Center?
  9. What was the next job you had after applying at a Wal-Mart Distribution Center? What city was it in? When did you start? What was your pay?
  10. Are you interested in being offered a job at a Wal-Mart Distribution Center? If you check no, it will not affect your eligibility for money or the amount of money to which you may be entitled. If you check yes, you will receive a letter informing you about the process for job interviews and placement on a priority hiring list.

    ______ No, I am not interested in a job offer.

    ______ Yes, I am interested in a job offer and want to receive more information about the process.
    What Distribution Center are you interested in being given priority consideration for a job?____________

I declare under penalty of perjury that the foregoing is true and correct.

Signature:
Claimant ____________________________ Date________________________

You should receive a notice informing you whether you are initially determined to be either:

(1) ineligible and the process for objecting to this decision; or,

(2) potentially eligible to receive money, which will be determined later; or,

(3) potentially eligible to receive money and because you indicated on this form that you are interested in a job at a distribution center, that your claim form, including job application will be forwarded to Wal-Mart for further processing.

NOTE: In order for you to receive any benefit from the settlement of this lawsuit, you may be required to provide additional information.

BEFORE YOU MAIL YOUR CLAIM, PLEASE CHECK TO MAKE SURE YOU:

Answered EVERY numbered question.

Signed your claim application.

Wrote today's date next to your signature.

Completed and enclosed a Wal-Mart job application.

Claim Form
Civ. No. S-99-414 GEB/DAD U.S. Dist Ct. (E.D.Ca)

This page was last modified on December 19, 2001.

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