COMPLAINT INQUIRY
NORTH DAKOTA DEPARTMENT OF LABOR AND HUMAN RIGHTS
SFN 52114 (7-2020)
600 E Boulevard Ave Dept 406
Bismarck ND 58505-0340
701-328-2660 Fax 701-328-2031
ND Toll-Free 1-800-582-8032
TTY: 1-800-366-6888
www.nd.gov/labor labor@nd.gov
ALL BLANKS MUST BE COMPLETED
COMPLAINANT INFORMATION
Name
Do you want to remain anonymous if possible?
Yes No
Mailing Address City
State
ZIP Code
Email Address
Do you consent to receiving correspondence exclusively at this email address?
Yes No
Telephone Number
Home Work Cell
Signature
EMPLOYER INFORMATION
Employee/Company Name
Owner/Manager Name
Mailing Address
City
State
ZIP Code
Email Address
Telephone Number
Person to Contact (if different from owner/manager)
Describe the Situation: (Be as specific as possible-include names, dates, places, etc.) (For final paycheck, please include: hourly rate,
hours worked, and dates worked)
NOTICE - Anything you submit to us in a paper form will be scanned to an electronic version and the original destroyed.
