Metropolitan Sewer District Equal Employment Opportunity And Contract Compliance Program Prevailing Wage Complaint Form (Page 3 of 3) in pdf

Metropolitan Sewer District Equal Employment Opportunity And Contract Compliance Program Prevailing Wage Complaint Form Page 3

YES

Were you paid time and

½ for hours worked over 40 per week?

Did employer provide written notice of job classification?

Did employer provide written notice of Prevailing Wage Rate?

Did employer provide written notice of name of Prevailing Wage Coordinator?

What Fringe Benefits were paid by the company?

None

Health Insurance $

Life Insurance $

Paid Vacation $

Paid Holidays $

Paid Sick Leave $

Pension $

Bonus

Other

Training _

Hours worked recorded by:

time card/sheet

called into office

recorded by foreman

other

SIGNATURE AND NOTARY

I hereby certify that this is a true statement to the best of my knowledge and belief.

____________________________________________________________

________________________________

Signature

Date

Sworn to and before me and subscribed by the said: _____________________________________________________

In my presence this ________ day of ______________________________________________, 200 _________________

__________________________________________________________ Notary Public

SEAL

MSDGC - Prevailing Wage Complaint – Page 3

Metropolitan Sewer District Equal Employment Opportunity And Contract Compliance Program Prevailing Wage Complaint Form Page 3