LABOUR STANDARDS COMPLIANCE OFFICE
NUNAVUT DEPARTMENT OF JUSTICE
PO Box 1000 Station 590, Iqaluit, Nunavut X0A 0H0
ᒪᓕᒐᓕᕆᔨᒃᑯᑦ Tel: 867 975 7293 / Toll Free: 1 877 806 8402 (NU only)
KAVAMATKOT APIKHOIYIT Fax: 867 975 7294
DEPARTMENT OF JUSTICE Email: LabourServices@gov.nu.ca
MINISTÈRE DE LA JUSTICE www.nucj.ca/LSO/
LABOUR STANDARDS COMPLAINT FORM
The information on this form is collected under the authority of the Labour Standards Act. A copy of this
summary form may be provided to the employer to assist labour services to fully and fairly investigate your
labour complaint filed under the Labour Standards Act.
SECTION A: INFORMATION ABOUT YOUR EMPLOYER
NAME OF EMPLOYER: (NAME OF COMPANY OR BUSINESS)
EMPLOYER ADDRESS TELEPHONE NUMBERS FAX NUMBERS
TYPE OF BUSINESS: EMPLOYMENT LOCATION:
________________________________________________________ ___________________________________________________
NAME OF SUPERVISOR: (PRINT) MANAGER / OWNER: (PRINT)
DATE OF EMPLOYMENT: START DATE: ______________ D / M / Y END DATE: ____________ D / M / Y
STILL EMPLOYED WITH EMPLOYER? YES _________________ NO: _________________
SECTION B: INFORMATION ABOUT YOU
FIRST NAME: MIDDLE INITIAL: LAST NAME:
YOUR JOB TITLE: RATE OF PAY:
HOW OFTEN WERE YOU PAID? DAILY WEEKLY EVERY TWO WEEKS OTHER
HOURS OF WORK PER DAY: NUMBER OF DAYS WORKED PER WEEK:
TOTAL HOURS WORKED PER WEEK:
DO YOU HAVE A RECORD OF THE HOURS WORKED FOR THIS EMPLOYER: YES __________________ NO _________________
IF YES, PLEASE ATTACH COPIES OF RECORDS TO THIS FORM
ARE YOU COVERED BY A COLLECTIVE AGREEMENT (UNION CONTRACT)? YES __________________ NO __________________
SECTION C: IDENTIFY YOUR WAGE COMPLAINT:
WAGES: _________________ REGULAR: ________________ OVERTIME: _____________ VACATION PAY: _________
GENERAL HOLIDAY PAY: ______________ TERMINATION PAY: __________________ OTHER: ________________
PROVIDE DETAILS ON SEPARATE PAGE
PRINT NAME:_______________________________ SIGNATURE: __________________________________ DATE: ________________
LABOUR STANDARDS COMPLIANCE OFFICE
ᒪᓕᒐᓕᕆᔨᒃᑯᑦ NUNAVUT DEPARTMENT OF JUSTICE
KAVAMATKOT APIKHOIYIT PO Box 1000 Station 590 Iqaluit Nunavut X0A 0H0
DEPARTMENT OF JUSTICE Tel: 867 975 7293 / Toll Free: 1 877 806 8402 (NU only)
MINISTÈRE DE LA JUSTICE Fax: 867 975 7294
LABOUR COMPLAINT FORM ATTACHMENT
COMPLAINT CONTACT INFORMATION:
FIRST NAME: __________________ MIDDLE INITIAL: ______ LAST NAME: _______________________________
MAILING ADDRESS: _______________________________________________________________________________
TEL: _____________________ OR ____________________________ FAX:_________________________________
Please ensure that the attached Complaint Form is completely filled out and signed. If it is
not completed in detail, the investigation of your complaint may be delayed.
To assist in the investigation, please provide the following information in addition to the
data requested on the attached complaint form.
_________________________
If you did not maintain a daily list of the hours you worked each day, please give the average number of
hours you worked each day.
_____________ Hours per day ______________ Hours per week
Did your pay rate change at any time during your employment? Yes ______ No ______ If yes, please give
details:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
GENERAL COMMENTS ON YOUR SPECIFIC WAGE COMPLAINT ISSUES LISTED ON ATTACHED COMPLAINT
FORM. USE BACK OF THIS PAGE IF NECESSARY - ADD ADDITIONAL NOTES ON SEPARATE PAPER.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Please sign, date and return with the complaint form:
____________________________________________________
Name (Please Print)
__________________________________________________ _______________________
Signature Date
LABOUR STANDARDS COMPLIANCE OFFICE
BOX 1000 Station 590 IQALUIT NUNAVUT XOA OHO
TEL: 1-867-975-7293 / TOLL FREE: 1-877-806-8402 ( NU ONLY ) FAX: 1-867-975-7294