2. The information on this form is considered confidential and will be treated as such.
4. Name
6. Phone Number
7. Email
9. Company Name*
10. Company Address*
12. Have you missed or lost wages?*
    -- Select One --YesNo
13. Have you been told to claim your missed/lost wages?
    -- Select One --YesNo
15. Has the company you work for laid off staff?*
    -- Select One --YesNo
16. When did the layoff occur (or will occur)?
17. How many workers were laid off?
19. Company Contact Name
20. Company Contact Phone Number
22. Please describe other work-related questions or concerns.
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24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit

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