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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