CONTRACTOR AND EMPLOYEE INFORMATION FORM



Name: [pic] Telephone: [pic]

Address: [pic] Zip Code: [pic]

Date of Birth: [pic] Age: [pic] Social Security: [pic]

Month/Day/Year

Date Employment Began: [pic] Date Employment Terminated: [pic]

Month/Day/Year Month/Day/Year

Employer Name: [pic] Telephone: [pic]

Address of Work: [pic] Zip Code: [pic]

Is Contract for Services valued in excess of $100,000? [Check one] Yes No Unsure

How many consecutive weeks did you work on this project?: [pic] Did you Work Full Time: Yes No

First Day Worked on this Contract: [pic] Last Day Worked on this Contract: [pic]

Rate of Pay $[pic] Hourly Daily Weekly Monthly

Statement/Explanation of Claim:

[pic]

I do solemnly declare and affirm under penalties of perjury that the matters and facts set forth herein, are true and correct.

SIGNATURE:        DATE:       

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LIVING WAGE COMPLAINT FORM

 Department of Labor

Division of Labor and Industry

Living Wage Unit

1100 North Eutaw Street, Room 606

Baltimore, MD  21201

Telephone Number: (410) 767-2232 • Fax Numb牥›㐨〱
㘷ⴷ㤲㘸䔋洭楡㩬Ꭰ奈䕐䱒义⁋洢楡瑬㩯汤汤汩癩湩睧条ⵥ汤牬浀牡汹湡⹤潧≶ᐁ汤汤汩癩湩睧条ⵥ汤牬浀牡汹湡⹤潧er: (410) 767-2986

E-mail: dldlilivingwage-dllr@

Rev. 7/2019

 

Department of Labor, Licensing and Regulation

Employment Standards Service

1100 North Eutaw Street, Room 607

Baltimore, MD  21201

Telephone Number: (410) 767-2357 • Fax Number: (410) 333-7303

E-mail: dldliemploymentstandards-dllr@

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Phone: 410.767.3068 Fax: 410.767.2986 dllr.labor/prev/livingwage

Martin O’Malley, Governor . Anthony G. Brown, Lt. Governor . Alexander M. Sanchez, Secretary

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