Canadian Armed Forces Class Action Intake Form

Date:*

Please note: we will keep confidential any information that you provide on this form, subject to receiving permission from you before disclosing it to any third party.

Claimant's Name:

Individual who was/is a member of the Canadian Armed Forces:

Name

First Middle Last

Other names Claimant may be known as, if any (including maiden name, if applicable):

Name

First Middle Last

Name

First Middle Last

Date of Birth:

Place of Birth:

Claimant’s Mailing Address:

Address:

Email:*

Home Phone:

Cell Phone:*

Other Phone:

Facsimile:

Claimant’s Preferred Form of Contact:

Email*

Reg. Mail:

Text:

Skype:

Contact Person (If Other Than Claimant) and His/Her Contact Information:

Name

First Last

Relationship to Claimant:

Address (Mailing):

Email*

Home Phone:

Cell Phone:*

Other Phone:

Facsimile:

Preferred form of contact:

Email*

Reg. Mail:

Phone*

Claimant’s Marital Status:

Status

Single:	Married:	Common Law:

Status

Divorced:	Widowed:	Separated:

Date

Divorce Date:	Widowed Date:	Separated Date:

Period of Service in Canadian Armed Forces:

Are you still a member of the Armed Forces?

Yes
No

If yes, what is your current rank?

If no, (i) what was the date of your discharge?

If no, (ii) what were the circumstances of your discharge (for example, honourable discharge for medical reasons)?

Please complete the following in reverse chronological order, i.e. starting with your most recent posting:

Base/Posting:

From	To

Base/Posting:

From	To

Base/Posting:

From	To

Base/Posting:

From	To

History of Your Rank:

Rank:

From	To

Rank:

From	To

Rank:

From	To

Rank:

From	To

A detailed description of any gender- and sexual-orientation-based discrimination, bullying, harassment and/or sexual assault by members of the Armed Forces that you experienced as a member of the Armed Forces. You should include a description of the impact(s) this had on you (for example, loss of sleep, post-traumatic stress disorder, anxiety), including any formal diagnoses you have received:

A detailed description of any complaints you made regarding gender- and sexual-orientation-based discrimination, bullying, harassment and/or sexual assault by members of the Armed Forces that you experienced, including any action taken in response to your complaint(s), the date of the complaint and the name of the individual(s) involved.

Complaint:

Any response to complaint:

Individual(s) complained of:

Date of complaint:

How did you learn about the proposed class action lawsuit:

Please provide any further information that you think may be relevant:

Thank you for completing this form. Upon receiving your contact information, we will add you to our database and will provide you with any relevant updates on the action. Please note that individual interviews and meetings are not required at this time.