EOLWD

For filing a written complaint with the Massachusetts Department of Labor Standards pursuant to 454 CMR 24.17 against an Employment or Placement Agency.

Complainant's Name:(Required)

First Last

Complainant's Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Complainant's Phone:

Complainant's Email:(Required)

Preferred Method of Contact:(Required)

Mail

Phone

Are you filing this complaint on your own behalf?

Yes

Other

If no, explain your relationship to the affected individual:

Name of Employment Agency/Placement Agency(Required)

Agency Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Agency Phone Number:

Agency email and website, if known

Name of Agency Representative, if known:

First Last

Describe the basis of your complaint, including, if applicable, names, dates, locations, job titles, promises made, documents received, fees charged, wages or deductions involved, and any communications with the agency.

Description of Complaint:(Required)

Laws or regulations believed to have been violated, If Known. List any sections of M.G.L. c. 140, §§ 46A–46R, M.G.L. c. 149, § 159C, or 454 CMR 24.00 that you believe may apply. Leave blank if unknown.

Please attach to this Complaint any documents you have supporting your allegations. Please also list any potential witnesses who may have information relevant to your Complaint, including their contact information, if known:

Have you filed this complaint with another agency or court?

Yes

If yes, please identify where and when:

Name

First Last

Upload up to 2 attachments. If you have more than 2 files to send please email nicholas.w.rose.@mass.gov and attach file that combined are no greater than 18MB per email.

Drop files here or

Max. file size: 10 MB, Max. files: 2.