ࡱ> FIEc wbjbj *8W\W\w\ \ ,D .XXXXX333$833333XX3XX3XW;Iu0 p_ppX3333333333 3333p333333333\ > :  OFFICE USE ONLY STATE OF NEVADA Department of Business and Industry OFFICE OF THE LABOR COMMISSIONER 1818 College Pkwy. #102 Carson City, Nevada 89706 (775) 684-1890 3300 West Sahara Ave Suite 225 Las Vegas, Nevada 89102 (702) 486-2650 EMPLOYMENT COMPLAINT (DO NOT USE THIS FORM TO CLAIM UNPAID WAGES OR COMMISSIONS)OFFICE USE ONLY COMPLAINT INFORMATION Name ________________________________________ First MI Last Address ______________________________________ Number Street Apt.# ______________________________________________________ City State ZIP Home phone (_____)____________________________ Email Address _________________________________ Job title ______________________________________ Department____________________________________ 1. Does this Employer currently employ you? Yes No 2. Did this Employer previously employ you? Yes No 3. Do you agree to be present at any Pre-Hearing Conferences or Administrative or Judicial Hearings if necessary, to present testimony and other evidence related to your Complaint? Yes No 4. Do you have or are you aware of any documentary evidence that will substantiate your complaint? Yes No If so, please provide copies. If you cannot provide copies, explain where the information is located. 5. Do you know of any witnesses that could provide additional information? Yes No If so, please provide names and information that will enable us to contact your witnesses. 6. Are you now or have you been involved in any lawsuits or other legal proceedings with this employer? Yes No If so, please explain on an attached sheet of paper. 7. Do you have the financial ability to hire an attorney to assist you with your Complaint? Yes No  EMPLOYER INFORMATION Business Name _____________________________ Location ___________________________________ Number Street ___________________________________________________ City State ZIP Mailing Address___________________________________ (if different) Number Street or PO Box ___________________________________________________ City State ZIP Business phone (_____)______________________ Email Address ______________________________ Owner/Manager/Supervisor Name: __________________________________________ First Last Type of Business ____________________________ Subject of Complaint _________________________ Is the activity upon which your complaint is based: ___ Company policy ___ Department policy ___ Problem with a particular Supervisor/Co-Worker  STATEMENT OF COMPLAINT (Please provide a short description of the employment practice that is the reason for your complaint. Be complete as to what the policy is, how it is communicated to the employees, when the incident(s) took place or whether it is ongoing and so forth. Use additional pages if necessary.) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ I CERTIFY THAT THE INFORMATION CONTAINED IN THE FOREGOING COMPLAINT IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. (SIGNATURE NOT NEEDED FOR ANONYMOUS OR FIELD COMPLAINTS) Signed _________________________________________ Date _____________________ ________________________________________________________________________________________________________________________________________________________________________ OFFICE USE ONLY COMPLAINT TAKEN BY: ________________________________________ ___ VERIFIED COMPLAINT ___ANONYMOUS COMPLAINT ___TELEPHONE/FIELD COMPLAINT INVESTIGATOR, IF ASSIGNED _____________________________________________ ALLEGED VIOLATION(S): _____________________________________ STATUTE: NRS __________ _____________________________________ STATUTE: NRS __________ _____________________________________ STATUTE: NRS __________ _____________________________________ STATUTE: NRS __________ HAS THIS EMPLOYER BEEN CONTACTED CONCERNING THE SAME OR SIMILAR VIOLATIONS IN THE PAST? YES ___ NO ___ UNKNOWN ___ DISPOSITION __________________________________________________________ Rev. 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