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
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c Employee c Survivor |
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Last Name First MI |
Claim Type |
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File Number |
Social Security Number (If Different from File No.) |
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Section 2 - District Office Point of Contact
District Office: c
Number of attached Employment Response Reports requiring action: ____________
Comments or other relevant information for CPWR:
DOL-POC NAME____________________________________________ DATE ___________________
SIGNATURE____________________________________________
TELEPHONE________________________________________________EMAIL__________________