Northwest WageLaw, LLC

A  t  t  o  r  n  e  y  s        a  t         L  a  w

Questionnaire


I. Employee Data:

                Last Name                  First Name          M.
Name:         
Address:  
City:      State Zip
Home:      Cell: Work:
Email:    

II. Employer Data

                Last Name                  First Name          M.
Name:         
Address:  
City:      State Zip
Immediate Supervisor's Name:
Date Hired(mm/dd/yy):
Date Employment Terminated (mm/dd/yy):
Job Title: Rate of Pay:

III. CIRCUMSTANCES OF TERMINATION

Fired? Any Notice? # Days: Quit?
#Days Notice of Intent to quit
Last Day of Work(mm/dd/yy): Any Written Employee Agreement:
When Last Wages Received(mm/dd/yy: Union Member:

IV. WAGES RECEIVED

Work Off the Clock? Ave # Hours per Day:
Work Overtime? Ave # Hrs Worked/Week
Overtime Rate Paid:
Vacation Hrs:
Other Facts:

 

 

NEWS

 
Northwest WageLaw, LLC
9220 SW Barbur Blvd
Suite 119-312
Portland OR 97219-5428
Telephone: (503) 295-0431
Fax: (503) 265-8244

EMAIL: Information@NorthwestWageLaw.com

 

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