Carmen v Health Carousel Consent Form "*" indicates required fields CONSENT FORM Pursuant to the Fair Labor Standards Act, 29 U.S.C. §216(b), I hereby Consent to Join and act as a Plaintiff in the above-captioned lawsuit. I agree to be bound by any adjudication or Court rulings in this Lawsuit, whether favorable or unfavorable. I hereby designate the Sommers Schwartz, P.C. and Melmed Law Group P.C. law firms to represent me in this Lawsuit. Claimant IDThis field is hidden when viewing the formLast nameClaimFormNoclick here for fileName: First Last Address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code E-mail:* Date of BirthLast Four SSNHEALTH CAROUSEL SETTLEMENT C/O ATTICUS ADMINISTRATION PO BOX 64053 SAINT PAUL, MN 55164 Unique IDSTUFF First Choice Second Choice Third Choice EmailThis field is for validation purposes and should be left unchanged.
