The Legal Arizona Workers Act Complaint Form (Page 3 of 4) in pdf

The Legal Arizona Workers Act Complaint Form Page 3

Page ___ of ___

When did you become aware of the information provided on the previous pages? ___________

____________________________________________________________________________

How did you become aware of the information provided on the previous pages?_____________

____________________________________________________________________________

Are you now an employee of the employer named on the first page?______________________

If not, have you previously been an employee of the employer named on the first page? ______

If you were previously employed by the employer named on the first page, when did you start,

when did you leave, why did you leave, where did you work, what positions did you hold, and

who were your immediate supervisors? ____________________________________________

____________________________________________________________________________

My Contact Information:

Name: ______________________________________________________________________

Home address: _______________________________________________________________

Home phone: ________________________________________________________________

Work phone: _________________________________________________________________

Cell phone: __________________________________________________________________

E-mail address: _______________________________________________________________

Signature:

I hereby affirm that the information set forth on all the pages of this form is true and correct.

Signature:_____________________________________

Date: ______________________

Rev 6/08 p3

The Legal Arizona Workers Act Complaint Form Page 3