Employment Information Form

First Name(required)

Last Name(required)

Email Address(required)

Phone Number(required)

Name of the Company you work(ed) for?(required)

Last Year of Employment at Company(required)

Still Employed 2023 2022 2021 2020

Method(s) of Compensation (eg. $18/hour, $40,000 salary)(required)

Average hours worked per week (eg. 40, 50, 60)(required)

Any Additional Information?

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