Nassau County Online Forms

2. Company / Organization Name*
4. Company / Organization Address*
6. City*
7. State*
8. Zip Code*
9. Phone Number*
11. Complaint relates to:*

    (check all that apply)

    1. Wages
    2. Health Benefits

    1. Paid Holidays
    2. Retaliation for Making a Complaint
13. Describe your Complaint*
15. Has your complaint been made to your employer?*

    1. Yes

    1. No
19. Optional Information
21. Complainant Name
22. Contract Number
24. Name of County Contract(s) that you have been working on:
26. Description of services you are performing under the contract(s) named above:
28. Date
    Date
Leave This Blank:


30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit

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