CPWR- Referral

 

 

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

 

 

 

 

c   Employee     c  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:       c  Cleveland          c  Jacksonville          c  Denver          c  Seattle

 

 

Number of attached Employment Response Reports requiring action:  ____________

 

 

Comments or other relevant information for CPWR:

                                                                                     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DOL-POC NAME____________________________________________ DATE ___________________

 

 

SIGNATURE____________________________________________

 

 

TELEPHONE________________________________________________EMAIL__________________