First Name*
Last Name*
Company Name
Company Number
Address of business (or individual if not a business)*
Town*
Country
Postal Code*
Telephone Number
Email Address*
I believe that I am/my business is a member of the “Publisher Partner” opt-in class in the collective proceedings before the UK’s Competition Appeal Tribunal: Ad Tech Collective Action LLP v (1) Alphabet Inc; (2) Google LLC; (3) Google Ireland limited; and (4) Google UK Limited (Claim Nos 1572/7/7/22 and 1582/7/7/23). I/my business wish/wishes to opt in to (i.e. be included in) these proceedings.
I confirm that the information provided above is true and correct to the best of my knowledge.
If you are under 18 years of age you will need to get your parent/guardian to sign this form on your behalf.
I agree that my electronic signature on this form is the equivalent of my handwritten signature. I further agree that my electronic signature on this form is as valid as my handwritten signature. I hereby confirm that the electronic signature has been produced with my consent.
I confirm I am over the age of 18I am opting in on behalf of the named individual as their parent/guardian
Date:
* Denotes a Required Field.
