Page 1 of ___ I, ___________________________________, reside at _____________________________________________ (Name) (Street Address) in _______________________, __________________________, ___________________________________ . (City) (County) (State) (Zip) My telephone number is: Area Code ( ) ______________________ . (Number) I have been employed by: ___________________________________________________________________ . (Name of Employer) Located at: _______________________________________________________________________________ . (Address of Employer) Employer' telephone number: Area Code ( s ) _______________________ . (Number) My job Classification is/was: __________________________________________________________________ NARRATIVE NOTE: The narrative must describe in detail the events surrounding the actions which you claim to be discharged or discrimination in violation of A.R.S. § 23-425. Therefore, you must include in your narrative the following information: (1) Craft or description of work you did, (2) The reason you believe your employer discharged you or discriminated against you, (3) The date and time the discharge or discrimination occurred, (4) Your location where the discharge or discrimination occurred, (5) Your supervisor' name, (6) The names, s addresses, and phone numbers of witnesses who will substantiate your claim, (7) A detailed description (including dates, times, locations, witnesses and persons involved) of events leading up to your discharge or discrimination, (8) Your objective in filing this discrimination complaint, (9) Are you employed at the present time? If so, by whom? (10) A phone number where you can be contacted between 7 a.m. and 6 p.m., Monday through Friday. You may use additional paper if needed.
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I have read and had an opportunity to correct this statement consisting of ____ pages and swear that the information contained herein is true and correct to the best of my knowledge and belief. Note: I am aware that it is unlawful for me to make any false statement, representation or certification in this document which is being fill pursuant to the Arizona Occupational Safety and Health Act of 1972 [A.R.S § 23-418 (H)]. Violation of this requirement is a Class 2 misdemeanor and carries a penalty up to $750.00. Signature of Complainant: ________________________________________ Date: ______________________
AUTHORIZATION FOR RELEASE OF EMPLOYMENT RECORDS
To Whom It May Concern: The undersigned __________________________________________, does hereby authorize The Industrial Commission of Arizona to obtain copies of any and all personnel and employment records involving his/her employment with ____________________________________________________________. Dated this ________ day of _____________________________, 20_____.