Full Name	*required
Address
City
State
Zip
Phone	*required
Fax
Email
Polo store where you worked
Approximate dates of employment
Describe wages not fully paid
Describe any overtime wage issues
Describe rest break experience
Describe experiences with loss prevention searches
Describe experiences with Polo's arrearage's program
Describe experiences with Polo's charge back or return policy program
If you believe you were mislead in any way by Polo, please describe how
Are you willing to sign a declaration describing these experiences?