*Asterisk means a required field.

Company Name

Federal Tax Identification Number

Street Address

City

State

Zip/Postal Code

First Name

Last Name

Title

Phone

Email Address

Annual Revenue

(Numbers only. Do not enter special characters such as "$" or "." Ex. $100,000 should be entered as 100000)

Number of Employees

I am submitting this request on behalf of a Business or Organization, not for myself as an individual

Acknowledgements

By checking this box, you acknowledge that you have read the Class Action Summary, which can be accessed using the “View Class Action Summary” button above.

By checking this box, you acknowledge that you believe your business is eligible to file a claim for the settlement.

Click the “SUBMIT” button below to begin the electronic authorization process to work with FRS.