CPWR- Referral (CP-1)

 

 

The CPWR Employment Information Request Form is to be completed in its entirety by a representative of the DOL.  It is not considered complete until the certifying Point of Contact (POC) has signed and dated the form. 

 

Section 1 - Employee Information

 

 

 

Employee              Survivor

Last  Name                                                    First                                                   MI

Claim Type

         

 

 

File Number

Social Security Number (If Different from File No.)

 

Section 2 - District Office Point of Contact

 

District Office:                       Cleveland            Jacksonville            Denver        Seattle

 

 

Number of attached Employment Response Reports requiring action: _________

 

 

Comments or other relevant information for CPWR:

                                                                                     

New Referral                                Supplemental Referral                    Amending Referral

 

 

 

 

 

 

 

 

 

 

 

 

 

DOL-POC NAME___________________________________ DATE______________

 

SIGNATURE____________________________________________

 

 

TELEPHONE________________________________________EMAIL____________