GOVERNMENT OF
THE VIRGIN ISLANDS OF THE UNITED STATES
DEPARTMENT OF LABOR
4401 Sion Farm STE 1 - Christiansted
2353 Kronprindsens Gade - Charlotte Amalie
St. Croix, VI 00820-4245
St. Thomas, VI 00802-2608
(340) 773-1994
(340) 776-3700
Fax (340) 773-0094
Fax (340) 774-5908
DIVISION OF LABOR RELATIONS
WAGE & HOUR SECTION
EMPLOYMENT INFORMATION FORM
WH-9
12/81
Wage Claim Form
I.
CLAIMAINT INFORMATION
CLAIM NUMBER
Name (Print first, middle & last name):
Mr. __________________________________
Date:____________________________
Ms.__________________________________
Phone:______________________Home
Phone:______________________Work
Phone:______________________Other
Social Security Number:______________________________
Physical Address:____________________________________________________Zip_____________
Mailing Address: ____________________________________________________Zip_____________
:
Check one of these boxes
Present employee of establishment
Former employee of establishment
Other ______________
(Specify: relative, union, etc.)
II.
ESTABLISHMENT INFORMATION
Name of Establishment: _________________________________________________________________
Address of Establishment: _______________________________________________________________
Authorized Representative: _____________________________________________ Phone: ___________
Estimate number of Employees__________ Does the firm have branches?
Yes
No
Don’t Know
If yes, name one or two locations: _________________________________________________________
Nature of establishment’s business: (
)
for example: hotel, restaurant, shoe store, construction, school, farm, hospital, etc.
III.
EMPLOYMENT INFORMATION
Period employed (month, year)
From:___________________
To: _____________________
(If still there, state present)
Date of Birth if under 21:
Month: __________________
Day: ______
Year:______
Give your Job Title: _____________________________________________________________________
Describe briefly the kind of work you do: ____________________________________________________