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WEST VIRGINIA DIVISION OF LABOR

REQUEST FOR ASSISTANCE

Are you a present employee: former employee: Other: Please give a brief description: NAME OF BUSINESS TO BE INVESTIGATED: BUSINESS PHONE: ADDRESS OF MAIN BUSINESS OFFICE: ADDRESS OR LOCATION WHERE WORK WAS PERFORMED: TYPE OF BUSINESS - MINING, CONSTRUCTION, RESTAURANT, etc.: JOB TITLE:
GIVE A BRIEF DESCRIPTION OF WORK PERFORMED:
WHAT IS YOUR COMPLAINT: Please give a description of the item you wish the West Virginia Division of Labor to investigate.	You have characters left.(Maximum characters allowed: 2222)
WHAT AMOUNT OF WAGES OR FRINGE BENEFITS ARE DUE YOU: TYPE NAME: DATE SUBMITTED:
BY MY SIGNATURE, I HEREBY CERTIFY THE ATTACHED INFORMATION TO BE TRUE AND ACCURATE.
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