Employee Complaint Form Bureau Of Contract Administration - City Of La
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1
2CITY OF LOS ANGELES EMPLOYEE COMPLAINT FORM
Please complete, sign and mail this form to:
Contact information:
(213) 847-2625
BUREAU OF CONTRACT ADMINISTRATION
1149 South Broadway, Suite 300
Tracking #: _______
Los Angeles, CA 90015
(OCC use only)
Attn: EEOE Section
Or email this to:
The information provided on this form is completely confidential.
If available/applicable, please attach a copy of your most recent paycheck to this form.
Mark the corresponding box(es) below for the Ordinance(s)/Program(s) you wish to file your complaint:
Living Wage Ordinance
Equal Benefits Ordinance
Affirmative Action/Equal Employment
Service Contract Worker Retention Ordinance
First Name:
Last Name:
MI:
Social Security #:
-
-
Your Street Address:
City:
State:
Zip Code:
Email Address:
Home Phone Number: (
)
-
Work Phone Number: (
)
-
Name of Supervisor:
Company Name:
Company Address:
City:
State:
Zip Code:
Company Phone Number: (
)
-
Work Site Address:
City:
State:
Zip Code:
City Department Awarding Contract (if known):
Your Current Job Title:
No
Are you part of a Union? Yes
Hourly Rate Paid: $
Overtime Rate Paid: $
Do you receive health benefits? Yes
No
If yes, how much do you pay for your benefits?
$
Employee Complaint (Be as detailed as possible. Continue on the next page if needed):
By signing below, I certify that the information provided in this document is true and correct to the best of my knowledge.
_________________________________________
______________________________________
Employee’s Signature
Date
FOR OCC USE ONLY
Analyst:
Date Received:
City Department:
Contract Number:
Form EEOE-1 (8/12)
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