Complaints Handling - Part III of the Canada Labour Code and the Fair Wages and Hours of Labour Act - OPD 700-10

Mr./Mrs./Miss/Ms
Last Name:
First or Given Name:
Middle Initial:

Mailing Address:
City and Province:
Postal Code:

Social Insurance Number:

Residence Telephone No.:
Telephone No. for messages:
Fax No.:

E-Mail:

Name of Employer, Company or Business:
Street Address and/or Employer's Mailing Address:
City and Province:
Postal Code:
Telephone No.:
Fax No.:

Type of Business:
Name of Supervisor:
Telephone No.:

Office Address (if different from Employer's Address above:

Is employer still in business?

• Yes
• No

Job Title:

First Day Worked for this Employer:

Last Day worked for this Employer:

• Still Employed
• Quit
• Fired
• Laid off

Salary/rate of pay $:

Specify if Paid by the Hour, Week, Month, etc.:

If paid by the Mile or by a Percentage of the Load, Commission, etc., please describe:

Number of Days Worked per week:

Number of Hours Worked per week:

Other:

Type of Pay Period

• Daily
• Weekly
• Every Two Weeks
• Twice a Month
• Monthly
• Other (please specify):

Where does your Employer Bank?

Do you have relevant records to support your complaint?

• Yes
• No

If yes, list records and attach photocopies to this form

Do you want your name to remain confidential?

• Yes
• No

Initial

If covered by a Union Contract, what is the name of the union?

Union Representative
Telephone No.

Was this Complaint made to another Government Representative?

• Yes
• No

If yes, specify
Date

I certify that all information provided is true and correct to the best of my knowledge.