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:
WHAT AMOUNT OF WAGES OR FRINGE BENEFITS ARE DUE YOU: TYPE NAME: DATE SUBMITTED:
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