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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 PERSON OR FIRM 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.
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.
The Division of Labor processes your personal information for appropriate and customary business purposes. Your personal information may be disclosed to other State Agencies or third parties in the normal course of business as needed to comply with state and/or federal laws. If you have any questions about the Division of Labor's use of your personal information, or would like a copy of the Division's complete privacy notice, please contact the webmaster@labor.org or the Division's Privacy Officer, John Junkins at 304-558-7890.