File No.

CPWR-Employment Response Report (CP-2)

New Referral Supplemental Referral Amending Referral

Section 1 – Employment to be Researched (To be completed by DOL)

 

Periods of Employment Requiring Verification

Period 1: Contractual Relationship Proof of Employment Employment on the Premises

Period 2: Contractual Relationship Proof of Employment Employment on the Premises

Period 3: Contractual Relationship Proof of Employment Employment on the Premises

Period 4: Contractual Relationship Proof of Employment Employment on the Premises

Section 2 – CPWR Research Results (To be completed by CPWR)

 

Additional Contacts Identified (If known):

 

CPWR Contact Information (Completed by person doing CPWR records search)

NAME_____________________________________________________ DATE _______________________

SIGNATURE________________________________________________

TELEPHONE________________________________________________EMAIL______________________