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DLSEForm205

DLSEForm205

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Published by Jacob Kiani

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Published by: Jacob Kiani on Jul 05, 2012
Copyright:Attribution Non-commercial

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07/05/2012

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 Direct any correspondence to
LABOR COMMISSIONER, STATE OF CALIFORNIARETALIATION COMPLAINTFOR OFFICE USE ONLY
TAKEN
 
BY DATE OFFICEVIOLATION
 
OF
 
SECTION NAME
 
OF
 
CODEASSIGNED
 
INVESTIGATOR CASE
 
NUMBER
PLEASE PRINT ALL INFORMATION
N
AME
H
OME
T
ELEPHONE
N
O
. C
URRENT WORK PHONE NO
. Y
OUR ADDRESS
-N
UMBER AND
S
TREET
,
 
A
PARTMENT OR
S
PACE
N
UMBER
,
 
C
ITY
,
 
Z
IP
C
ODE
 S
EX
S
OCIAL
S
ECURITY
C
ALIFORNIA
D
RIVER
L
ICENSE
N
O
. 
DATE OF BIRTH
 N
AME OF BUSINESS
E
MPLOYER
S NAME
 
 
C
ORPORATION
 
 
P
ARTNERSHIP
 
 
S
OLE OWNER
 A
DDRESS OF
B
USINESS
-N
UMBER AND
S
TREET
,
 
C
ITY
,
 
Z
IP
C
ODE
T
ELEPHONE NUMBER
 A
DDRESS WHERE YOU WORKED IF DIFFERENT THAN ABOVE
D
ATE OF HIRE
?
 
Y
OUR
D
EPARTMENT AND
J
OB
T
ITLE
R
ATE OF PAY
 N
UMBER OF HOURS WORKED
? P
ER
D
AY
P
ER
W
EEK
N
AME OF SUPERVISOR
T
YPE OF BUSINESS
E
STIMATED
N
O
.
EMPLOYEES
 W
AS
Y
OUR
J
OB
U
NION
? I
F YES
,
NAME AND ADDRESS OF UNION
? T
ELEPHONE
 W
ERE YOU DISCHARGED
?
 
Y
ES
 
 
N
O
 I
F YES
-D
ATE
B
Y WHOM
?
 
N
AME AND TITLE
 A
RE YOU STILL WORKING FOR THIS EMPLOYER
? 
 
Y
ES
 
 
N
O
D
ID YOU NOTIFY YOUR EMPLOYER OF INTENTION TO FILE A CLAIM WITH THELABOR COMMISSIONER
?
 
Y
ES
 
 
N
O
I
F YES
-D
ATE
 N
AME AND TITLE OF PERSON NOTIFIED
? D
ID YOU FILE A SAFETY COMPLAINT
?
 
Y
ES
 
 
N
O
 I
F YES
-D
ATE
W
ITH WHOM
-N
AME AND ADDRESS
? D
ID YOU NOTIFY
OSHA?
 
Y
ES
 
 
N
O
 I
F
Y
ES
-D
ATE
W
HICH OFFICE
?
 
N
AME AND TITLE OF PERSON
(
S
)
YOU BELIEVE RETALIATED AGAINST YOU
? W
HAT REMEDY ARE YOU SEEKING THROUGH THIS DIVISION
?H
AVE YOU FILED WITH ANY OTHER GROUP OR AGENCY
?
 
 
Y
ES
 
N
O
I
F YES
,
WHICH OFFICE
?
 
___________________________________________________________________________________________________________________________________
N
AME
A
DDRESS
T
ELEPHONE
 A
RE YOU BEING REPRESENTED BY AN ATTORNEY
?
 
Y
ES
 
N
O
 
____________________________________________________________________________________________________________________________________
N
AME
A
DDRESS
T
ELEPHONE
 INTERPRETER
 
NEEDED?
 
 
Y
ES
 
 
N
O
IF
 
INTERPRETER
 
NEEDED,
 
WHAT
 
LANGUAGE?
 L
IST NAME
,
JOB TITLES AND TELEPHONE NUMBER
(
IF POSSIBLE
)
OF WITNESSES
,
CO
-
WORKERS OR THOSE YOU FEEL COULD PROVIDE
 
EVIDENCE IN YOUR SUPPORT TO THE ACTS YOU ARE COMPLAINING ABOUT
.
 
U
SE ADDITIONAL SHEETS
 
DLSE
205
 
(R
EV
.
 
11/2010)
RETALIATION COMPLAINT
 / 
ENGLISH
1
 
 
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