Roundup® CLASS ACTION INTAKE FORM

Please note: we will keep confidential any personal identifying information that you provide on this form, subject to first receiving permission from you.

Please complete this form if you wish to be kept informed of the progress of this case.

Completing this form creates no financial obligation for you. It does not create a lawyer/client relationship between yourself and Wagners (or any of its lawyers).

By completing this form you are asking Wagners to include you in our list of potential members in this class action, but our firm is not agreeing to represent your personal interests. Wagners will represent the interests of the class as a whole.

The definition of the class of people included in this class action may in the future change or be modified. We may not inform you or the public if and when the class definition changes. It is your responsibility to ensure that your own personal interests and legal rights are being protected. You may wish to obtain independent legal advice in order to determine whether it would be in your best interest to pursue independent litigation in this matter. Should you meet the definition of a class member, you may be entitled to compensation if there is a final judgment or settlement in favour of the class. However, the class definition may change over time, and there is no guarantee of compensation regardless of the class definition.

ROUNDUP®

CLASS ACTION INTAKE FORM

Date:*
MM slash DD slash YYYY
THIS FORM IS FOR INFORMATIONAL PURPOSES ONLY. IT IS NOT A CLAIM FORM AND DOES NOT GUARANTEE ELIGIBILITY FOR ANY EVENTUAL COMPENSATION.

The current proposed class definition requires individuals to have applied (i.e. not mere exposure) Roundup, on more than two times in a 12-month period and more than ten applications over their lifetime, and to have been diagnosed with Non-Hodgkin’s Lymphoma. Individuals who are the living spouse, child, grandchild, parent, grandparent, or sibling of an individual as defined above can also submit an intake form to be kept informed of the potential to submit a future claim.
How did you learn about the proposed class action lawsuit?
SECTION I: CONTACT INFORMATION
Claimant’s Name*
First Middle Last
Other names Claimant may be known as, if any (including maiden name, if applicable):
First Middle Last
First Middle Last
Claimant’s Date of Birth:
MM slash DD slash YYYY
Claimant’s Place of Birth:
Claimant’s Health Card #:
H/C Issuing Province:
Claimant’s Mailing 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:
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: (Please Circle)
Status
- Single
- Married
- Common Law
- Divorced
- Widowed
- Separated
SECTION II: PRODUCT USE INFORMATION
PART A: PERSONAL APPLICATION of Roundup®
Have you personally applied Roundup®?
- Yes
- No
In terms of your application of Roundup®, was it: (if both, please check both “Yes”)
(i) Commercial/occupational application?
- Yes
- No
(ii) Residential application?
- Yes
- No
(If not, and you are completing this form because your family member has been diagnosed with Non-Hodgkin’s Lymphoma after applying Roundup®, please go to Section II, Part B at page 10 of this form to complete the section applicable to you.
Do you have any proof of purchase and application of Roundup®, such as receipts, invoices etc.?
- Yes
- No
If yes, please provide copies of such receipts, invoices or other proof, and maintain the original copies for your records.
If you have personally applied Roundup®, please provide the following information on page 4 regarding your application of Roundup®. If your application of Roundup® was in different locations at different times, please provide specifics for each location and period of application, completing the following table in reverse chronological order, i.e. starting with the most recent location of application of Roundup® (see below example).

If you do not have enough room to provide information on this Intake Form, please attach another document detailing information about your application of Roundup®.

Location and Province of application of Roundup®? (Please indicate if for commercial purposes or residential purposes) (e.g. Sheep farm, ABC County, Province; approx. 50 acres, commercial.)	From YYYY to YYYY (e.g. 2008 - 2015)	Spraying Season (months of use) (e.g. April to November)	How did you apply Roundup® (e.g. sprayer)? (e.g. Hand-sprayer, to spot-spray.)	Approximately how often did you apply Roundup®? (e.g. Daily from Apr – July, then 3 times per week from July – Nov.)

What attire did you typically wear when applying Roundup®? (e.g. coveralls, T-shirt, sealed suit, sneakers, boots, sandals, gloves, mask/no mask etc.)
Did you use and/or were you exposed to any glyphosate-based herbicides other than Roundup®? If so, please indicate which glyphosate-based herbicides you used, when and with what frequency:
Have you been diagnosed with any form of Non-Hodgkin’s Lymphoma?
- Yes
- No
If yes, when?
What type of Non-Hodgkin’s Lymphoma were you diagnosed with?
Who made the diagnosis of Non-Hodgkin’s Lymphoma?
Have any of your family members also been diagnosed with Non-Hodgkin’s Lymphoma?
- Yes
- No
What symptoms, if any, have you developed as a result of your diagnosis of Non-Hodgkin’s Lymphoma and/or associated treatment for Non-Hodgkin’s Lymphoma?
Have you suffered from a relapse or recurrence of Non-Hodgkin’s Lymphoma?
- Yes
- No
If yes, when?
Please describe the type and duration of treatment you have undergone for Non-Hodgkin’s Lymphoma
Have you been diagnosed with any conditions or illnesses in addition to Non-Hodgkin’s Lymphoma? If so, please specify:
Please generally describe your health history, including any other diagnosed conditions or diseases, and/or major surgeries:
Are you a smoker or former smoker?
- Yes
- No
What is your smoking history / frequency?
What is/was your occupation?
SIN*:

* This will only be used in conjunction with the Claimant’s consent and authorization to obtain certain medical / other records in the future, should it be necessary.
Have you lost any income as a result of your diagnosis of Non-Hodgkin’s Lymphoma and/or associated treatment for Non-Hodgkin’s Lymphoma?
- Yes
- No
- Unsure
Approximate amount (CAD):
Did you incur any expenses (e.g., medications, travelling for medical treatment, etc.) as a result of your diagnosis of Non-Hodgkin’s Lymphoma and/or associated treatment for Non-Hodgkin’s Lymphoma?
- Yes
- No
- Unsure
Approximate amount (CAD):

We ask that you please save all receipts / documentation of expenses for the time being.
Please generally describe how your diagnosis of Non-Hodgkin’s Lymphoma and/or treatment have impacted your activities of daily living, enjoyment of life (etc.)
Please note that we will never contact any persons listed below without your express consent.
DOCTOR(S):
Provide details of doctors who would possess medical records related to any injuries and/or treatment you received arising from your application of Roundup®:
Name:
Phone:
Address:
Name:
Phone:
Address:
Name:
Phone:
Address:
Name:
Phone:
Address:
PHARMACIES:
Provide details of pharmacies that would possess prescription records verifying medication you received arising from your application of Roundup®:
Name:
Phone:
Address:
Name:
Phone:
Address:
OTHER PHYSICIAN(S)/HOSPITAL(S):
Provide details of any Medical Specialists/Hospitals/Physiotherapists/Psychologists/ Psychiatrists/Counsellors that have treated you as a result of your application of Roundup®:
Name:
Phone:
Address:
Name:
Phone:
Address:
Name:
Phone:
Address:
Name:
Phone:
Address:
MEDICAL HISTORY/DOCTORS
Provide details of your medical history, such as former G.P.s, Hospitals, Specialists etc.:
Name:
Phone:
Address:
Name:
Phone:
Address:
Name:
Phone:
Address:
Name:
Phone:
Address:
PART B: FAMILY MEMBER’S APPLICATION of Roundup®
If you are completing this form because your family member has been diagnosed with Non-Hodgkin’s Lymphoma after applying Roundup®, please provide the information below.
If you have personally applied Roundup®, (and thus you are not completing this form because your family member has been diagnosed with Non-Hodgkin’s Lymphoma after applying Roundup®), you do not need to fill out Part B.
Family member’s name who applied Roundup®:
Name
First Middle Last
Other names your family member may be known as, if any (including maiden name, if applicable):
Name
First Middle Last
What is your relation to this family member?
Family member’s Date of Birth:
MM slash DD slash YYYY
Family member’s Place of Birth:
Did your family member use and/or were they exposed to Roundup®?
- Yes
- No
In terms of your family member’s application of Roundup® was it: (if both, please check both “Yes”)
(i) Commercial/occupational application?
- Yes
- No
(ii) Residential application?
- Yes
- No
Was your family member diagnosed with Non-Hodgkin’s Lymphoma?
- Yes
- No
If yes, when?
What type of Non-Hodgkin’s Lymphoma was your family member diagnosed with?
Have any other family members also been diagnosed with Non-Hodgkin’s Lymphoma?
- Yes
- No
Did your family member suffer from a relapse or recurrence of Non-Hodgkin’s Lymphoma?
- Yes
- No
If yes, when?
Was your family member diagnosed with any conditions or illnesses in addition to Non-Hodgkin’s Lymphoma? If so, please specify:
Please generally describe your family member’s health history, including any other diagnosed conditions or diseases, and/or major surgeries:
Is your family member a smoker or former smoker?
- Yes
- No
What is / was their smoking history / frequency?
Is your family member still living?
- Yes
- No
If your family member is still living, did your family member fill out an Intake Form with Wagners?
- Yes
- No
- Unsure
If not, what was their date of death?
MM slash DD slash YYYY
Was the cause of death Non-Hodgkin’s Lymphoma, or related to that diagnosis?
- Yes
- No
- Unsure
Did your family member have an administrator or executor of their estate?
- Yes
- No
- Unsure
Were you appointed the administrator or executor of your family member’s estate?
- Yes
- No
- Unsure
To the extent you can provide the following information, please provide information on page 12 regarding your family member’s application of Roundup®. If your family member’s application of Roundup® was in different locations at different times, please provide specifics to the extent possible for each location and period of application, completing the following table in reverse chronological order, i.e. starting with the most recent location of application of Roundup® (see below example).

If you do not have enough room to provide information on this Intake Form, please attach another document detailing information about your family member’s application of Roundup®.

Location and Province of application of Roundup®? (Please indicate if for commercial purposes or residential purposes) (e.g. Sheep farm, ABC County, Province; approx. 50 acres, commercial.)	From YYYY to YYYY (e.g. 2008 - 2015)	Spraying Season (months of use) (e.g. April to November)	How did your family member apply Roundup® (e.g. sprayer)? (Hand-sprayer, to spot-spray.)	Approximately how often did your family member apply Roundup®? (e.g. Daily from Apr – July, then 3 times per week or as needed from July – Nov.)

What attire did your family member typically wear when applying Roundup®? (e.g. coveralls, T-shirt, sealed suit, sneakers, boots, sandals, gloves, mask/no mask etc.)
Did your family member use and/or were they exposed to any glyphosate-based herbicides other than Roundup®? If so, please indicate which glyphosate-based herbicides were used, when and with what frequency:
Did you incur any expenses for the benefit of your family member who was diagnosed with Non-Hodgkin’s Lymphoma after they applied Roundup®, in relation to their diagnosis and/or treatment?
- Yes
- No
- Unsure
Approximate amount (CAD):
Did you incur any travelling expenses for the benefit of your family member who was diagnosed with Non-Hodgkin’s Lymphoma after they applied Roundup®, in relation to their diagnosis and/or treatment?
- Yes
- No
- Unsure
Approximate amount (CAD):
Did you lose any income as a result of your family member’s diagnosis of Non-Hodgkin’s Lymphoma after they applied Roundup®, in relation to their diagnosis and/or treatment?
- Yes
- No
- Unsure
Approximate amount (CAD):
Did you provide any valuable services (such as nursing and housekeeping, increased services around the home your family member used to carry out etc.) as a result of your family member’s diagnosis of Non-Hodgkin’s Lymphoma?
- Yes
- No
- Unsure
Please generally describe how your family member’s diagnosis of Non-Hodgkin’s Lymphoma and/or treatment have impacted their activities of daily living, enjoyment of life (etc.)
Please note that we will never contact any persons listed below without your express consent.
DOCTOR(S):
Provide details of doctors who would possess medical records related to any injuries and/or treatment you received arising from your family members’ application of Roundup®:
Name:
Phone:
Address:
Name:
Phone:
Address:
Name:
Phone:
Address:
Name:
Phone:
Address:
PHARMACIES:
Provide details of pharmacies that would possess prescription records verifying medication you received arising from your family members’ application of Roundup®:
Name:
Phone:
Address:
Name:
Phone:
Address:
OTHER PHYSICIAN(S)/HOSPITAL(S):
Provide details of any Medical Specialists/Hospitals/Physiotherapists/Psychologists/ Psychiatrists/Counsellors that have treated your family member as a result of their application of Roundup®:
Name:
Phone:
Address:
Name:
Phone:
Address:
Name:
Phone:
Address:
Name:
Phone:
Address:
MEDICAL HISTORY/DOCTORS
Provide details of your family member’s medical history, such as former G.P.s, Hospitals, Specialists etc.:
Name:
Phone:
Address:
Name:
Phone:
Address:
Name:
Phone:
Address:
Name:
Phone:
Address:
SECTION III: OTHER INFORMATION
Please provide any further information that you think may be relevant:
Thank you for completing this informational 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.