Living Wage Act – Covered Employee Complaint Form

First Name *

Last Name *

Phone *

Email *

We will send a copy of this form to your email for your records.

Address *

City *

State *

Zip *

Covered Employer

Job Title

Immediate Supervisor Name

Immediate Supervisor Title

Employer Phone

Employer Address

Employer City *

Employer State

Employer Zip

Worksite Address if different than above

NATURE OF COMPLAINT

Attach any relative documents

Drop your files here or click here to upload You can upload up to 5 files.

Allowed files types: pdf, doc, docx, jpg, png

Your signature (mouse, stylus or finger compatible) *

Date