HTML Preview Covered Employee Complaint page number 1.
Steven Bellone Frank Nardelli
Suffolk County Executive Commissioner
SUFFOLK COUNTY DEPARTMENT OF LABOR, LICENSING & CONSUMER AFFAIRS
DOL-LW-8 1/15
COVERED EMPLOYEE COMPLAINT FORM
Living Wage Law, Suffolk County Code, Chapter 575 (2001)
COMPLAINANT: _________________________ TELEPHONE #: ______________________________
ADDRESS: ______________________________________________________
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JOB TITLE: _____________________________________
IMMEDIATE SUPERVISOR NAME: _____________________________________________________
IMMEDIATE SUPERVISOR TITLE: _____________________________________________________
COVERED EMPLOYER: ________________________________________________________________
ADDRESS: ____________________________________________________________________________
_______________________________TELEPHONE #: ______________________________
WORKSITE ADDRESS IF DIFFERENT FROM ABOVE: _____________________________________
________________________________________________________________________________________
NATURE OF COMPLAINT
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
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ATTACH OTHER SHEETS & DOCUMENTS AS NEEDED
______________________________________ ______________________
(Signature of Complainant) (Date)
Forward to:
Suffolk County Department of Labor, Licensing & Consumer Affairs
Local Law Compliance
P.O. Box 6100
Hauppauge, NY 11788-0099