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Complainant Information


(first/middle/last)


First Name: *
Middle Name: *
Last Name: *
Tel: *
Cell:
Email Address:
Mailing Address: *
Civic Address:
City/Town/Village: *
Province: *
Postal Code:
Job Title:
Employment period (from):
(MM/DD/YYYY)
Employment period (to):
(MM/DD/YYYY)
Reason for termination:
lay off
dismissed
quit
Hours of work per week:
Rate of pay:
Pay Period:
Weekly
Biweekly
Twice-monthly
Amount of monies owed:
Business Name


Business Name: *
Telephone: *
Cellular Phone:
Mailing Address: *
Civic Address:
City/Town/Village:
Province: *
Postal Code: *
Owner's Name:
Manager's Name:
Nature of Complaint


Complaint:
Remedy Requested


Remedy:
Conditions or Arrangements


List (if any) conditions or arrangements agreed to between yourself and your employer at the time of hiring or during your employment period which may have an effect on this claim.
Conditions:
Current Situation


Do you owe the employer any monies?:
If yes, describe:
Do you have any of the employer's goods or equipment?:
If yes, describe:
Contact Information


List persons (if any) who can help verify your claim.
Name:
Job Duty:
Address:
Telephone:
Nature of Information:
What is the nature of the information that the witness can provide?
Name:
Job Duty:
Address:
Telephone:
Nature of Information:
What is the nature of the information that your witness can provide?
Additional Information


Outline here any additional information that will help support your claim. List in detail days, hours and pay period(s) for which monies are owed.
Information:
Filing the Claim


Before filing this claim with the Employment Standards Branch, you should make your employer aware of the basis of your complaint and attempt to resolve the matter. The results of your discussion should be outlined here.
Results of Your Discussion:
Documentation


You may be required to forward documents which help support your claim i.e.,pay statements, cheques, record of employment, etc.
1:
2:
3:
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