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 ___________________