STATUS LETTER REQUEST

Employer / License #*

EmployerXG username is acceptable if unable to provide employer or license #

Company Name*

Address*

City, State Zip*

Requester Name*

(First Name, Last Name)

Requester Email*

Please Note: A Status Letter will be generated with the Work Periods and Areas selected below. If you require a Status Letter per Work Period and corresponding Area, please submit multiple form requests.

Work Period*

(Select all that applies)

Select

Area*

(Select all that applies)

Select

File Upload

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