Mettrum Pesticide Class Action Intake Form

Date:*
MM slash DD slash YYYY
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:
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:
MM slash DD slash YYYY
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:
Phone*
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:
Product information
Did you receive notification of the voluntary or involuntary recalls of the affected product from Mettrum?
- Yes
- No
Did you consumed recalled products:
If yes, (i) how were you notified?
When did you consume the recalled product?
From To

When did you consume the recalled product?
Did you consume dried marijuana and/or cannabis oil? Please describe.
Please provide the following information for the recalled product that you consumed:
Lot number:

Or
Serial number:
Did you directly pay out of pocket for the recalled product (check one)?
- Yes
- No
If yes, how much in total did you pay for the recalled product?
If someone else paid for the recalled product for you, who paid?
For what medical condition was medical marijuana prescribed for you?
What symptoms, if any, have you developed as a result of using the affected product?
Have you been to a physician about this issue?
- Yes
- No
A description of any complaints you made to Mettrum regarding the affected product:
Complaint:
Any response to complaint:
Date of complaint:
MM slash DD slash YYYY
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.

Single:	Married:	Common Law:

Divorced:	Widowed:	Separated:

Divorce Date:	Widowed Date:	Separated Date:

From	To

Mettrum Pesticide Class Action Intake Form

Mettrum Pesticide Class Action Intake Form

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:

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

Claimant’s Mailing Address:

Claimant’s Preferred Form of Contact:

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

Preferred form of contact:

Claimant’s Marital Status:

Product information

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.