Address:


City:


County:


State:

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Zip:

What is your job title?

What is your employer?

Are you paid overtime when you work more than 40 hours in a week?:

— Yes No

If YES
Do you ever work off-the-clock? If yes, how many hours per week?:

If NO
Are you a manager who supervises two or more full time employees and has the power to hire or fire other employees?:

— Yes No

Do you have the independent authority to make important financial or policy decisions on behalf of your employer?:

— Yes No

Was your salary ever reduced based on the amount of work you have performed in a given workweek, or based on the quality of work:

— Yes No