You may remain anonymous on the form below or when you call the Tip Line at (401)
462-WAGE (9243). The more information provided, however, will help DLT examine your
complaint. Thank you.
Rhode Island Dept. of Labor and Training
LABOR STANDARDS – BLDG. 70-2
1511 Pontiac Avenue, P.O. Box 20390,Cranston, RI 02920-0944
PAY EQUITY COMPLAINT FORM
Employee information:
Name:
Mr.
Mrs.
Ms._______________________________Soc. Sec.#______________
Address:________________________________________________________________
City: ___________________________ State:______ Zip Code: __________________
Date of birth:_________ Home phone:______________ Cell phone: _______________
Title of position: ________________________________ Email: ___________________
Employer information:
(Complaint will not be accepted unless this section is completed.)
Company name:__________________________________ Phone:_________________
Address:_______________________________________________________________
City: ___________________________ State:______ Zip Code: __________________
President/Owner Name: __________________________ Title:____________________
Local Manager Name: _____________________________________________________
Place work was performed if different from above: ______________________________
Date of hire: _______________
Last day worked: _______________
(mm/dd/yy)
(mm/dd/yy)
Were you discharged?
Yes
No
or did you leave?
Yes
No
Are you collecting Unemployment Insurance?
Yes
No
Have you discussed the issue of pay equity with your employer?
Yes
No
WHAT WAS THEIR RESPONSE?
When did you last speak with your employer?___________________________________
With whom did you speak? __________________________ Title:__________________
Company telephone number (if different from above):____________________________