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The form collects employer/client details, the employer representative’s organization, title, contact information, and signature, and requires choices indicating role type. It also gathers additional legal and labor-context information (pending legal actions, correspondence, bankruptcy, collective bargaining agreements, and grievances). 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Employer/Client Information  \nDate:    \nCase File Identification Number or Order to Comply Number:   Employer/Business Name(s) :    \nSubject of Claim (e.g. , minimum wage, overtime etc. ) :    \nComplainant Name (if known) :    \n2. Employer Representative Information  \nOrganization/Firm Name:   Name:    \nTitle:    \nChoose One:  Attorney  Accountant  Other:    \nSignature:    \nAddress:   Telephone:   Fax:   Email:    \nLS 11.1 (03/23) Page 1 of 2  \n3. Additional Information (please complete all sections)  \nIs your client involved in any pending legal actions regarding labor laws (lawsuits, etc. )?  \n Yes  No If yes, please provide details:    \nHave any claimants or claimant representatives corresponded directly with you or your client regarding the subject of our investigation?  Yes  No  \nIf yes, please explain and provide copies of all correspondence along with this form.  \n___________________________________________________________________________  \nIs your client involved in a pending bankruptcy matter?  Yes  No  \nIf yes, please provide details including docket number, date, etc.:    \n___________________________________________________________________________  \nIs your client signatory to a collective bargaining agreement?  Yes  No  \nIf yes, please provide the union name and contact information, if available:    \n___________________________________________________________________________  \nIf yes, are there any pending grievances related to labor law issues?  Yes  No  \nIf yes, please provide details:    \n4. Client(s) Authorization: I authorize the above named individual and/or organization to  \nrepresent me in matters involving the case indicated above. You have my permission to communicate or share information with my representative as necessary.  \nClient Name and Title:   Client Signature:    \nClient Name and Title:  \n__________________________________________________________  \nClient Signature:   LS 11.1 (03/23) Page 2 of 2","cbCainl4hGSF7Rm6","https://ap.wps.com/l/cbCainl4hGSF7Rm6","pdf",1092752,"English","# 1. Employer/Client Information\n# 2. Employer Representative Information\n# 3. Additional Information\n# 4. Client(s) Authorization","[{\"question\":\"What information must be completed in the employer/client section?\",\"answer\":\"Fill in the date, case file identification/order to comply number, employer/business name(s), subject of claim, and complainant name (if known).\"},{\"question\":\"What additional legal and labor-related questions are included?\",\"answer\":\"The form asks whether the client has pending legal actions, pending bankruptcy matters, is signatory to a collective bargaining agreement, and whether there are pending grievances related to labor law issues, including details if “Yes.”\"},{\"question\":\"What does the client authorization section allow the representative to do?\",\"answer\":\"The client authorizes the named individual and/or organization to represent them and permits communication or sharing of information with the representative as necessary for the case.\"}]","Division of Labor Standards - Letter of Representation - Employer Representative - Authorization and Information Form | PDF",1789496694]