Chipotle Sign Up Form

Please take a few minutes to submit your information below. This information will help us identify class members that may be entitled to some compensation or other relief.

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone
Date of Chipotle visit: If you were short-changed on more than one visit, please share additional details in the additional comments section.
MM slash DD slash YYYY
Chipotle Location: Select One
Do you have a receipt?
Amount you were short changed
Additional Comments