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Employment Standards Complaint Form

This form should be used if all other attempts to resolve the issue have been unsuccessful.

Fields marked with a red star (*) are mandatory.

Complainant Information


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

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

Remedy Requested

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.
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.
Job Duty:
Nature of Information:
What is the nature of the information that the witness can provide?
Job Duty:
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.
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:

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

Do you want a copy of the form?

Please send me a simple text-only version of the information I submitted.
Please send me an Acrobat version of the form, with the information I've entered above filled in, that I can print and save.
Please send me both the text-only version and the PDF.
Important Note: Email is not, by its very nature, a secure medium; if you choose to have your form emailed to you, the information you entered will be transmitted over the public Internet to your email box.

Email to address:

Submit the Form

* There are several contact persons for this form. Please select the contact person from the list below to whom your form should be directed.

Hazel Walsh (Justice and Public Safety )
Shane Bernard (Finance )
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When you click here, the information you've entered above will be sent to the public servant responsible for receiving and processing this form. If you've opted to receive an Acrobat version of the form by email, you will receive this file shortly.
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