Non-Payment Of Wage And Workplace Complaint Form- Page 1
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Non-Payment of Wage and Workplace Complaint Form- Page 1
Please provide as much information as you can on this form and mail it to the above address.
Employee Information
First name
Middle name
Last name
Social Security Number*
Date of birth
Gender M
F
(month/day/year)
Current mailing address
City
State
Zip
Email
Home phone
Cell phone
Emergency contact name and phone
(friend / family member who can reach you)
Mailing address
City
State
Zip
Start date of employment
End date of employment
(month/day/year)
(month/day/year)
Please Read: Under most circumstances, the text of your complaint will be considered a public record and be available to
any member of the public upon request. In response to such a request, we generally will not disclose your name, address,
phone number, or any other information that identifies you and will not disclose this form in response to any request that
specifically seeks the complaint you submitted. Your record in its entirety may, however, be disclosed to law enforcement
and regulatory agencies who may assist in resolving your complaint.
*Providing a Social Security Number is voluntary. It will aid in processing your complaint, but we will proceed without one.
Wage/Workplace Complaint Form
Page 2 of 4
Rev. 12/2008
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