Appendix

NOTE: This form is to be used with respect to the Successor Employer provisions of the contract.

1. Company name:

2. Address:

3. Tel. No.(999-999-9999):

4. Fax No.(999-999-9999):

5. Workplace address:

6. Contract No.:

List below all your employees working at this workplace and give each employee, in box 7, a separate number. If more space is required for any of these items, attach additional pages and make reference to the employees' separate number and to the item number.

7. Employee name:

No.:

8. Address:

9. Tel. No.(999-999-9999):

10. Date of hire (YYYY-MM-DD):

12. Wage rates :

13. Cost and period of each benefit :
Date (YYYY-MM-DD):

14. Job classification or description:

15. Number of weeks worked at premises during the 26 weeks preceding the date of request for information.

16. Number of hours worked in regular non-overtime work week.

17. If hours of work vary from week to week, number of non-overtime hours for each week worked during the 13 weeks preceding the request for information.

Week 1:

Week 2:

Week 3:

Week 4:

Week 5:

Week 6:

Week 7:

Week 8:

Week 9:

Week 10:

Week 11:

Week 12:

Week 13:

Dated (YYYY-MM-DD):

21. Name of authorized company representative:

Signature: _______________________________

Date (YYYY-MM-DD) 2:

1. PWGSC
2. Bidder(s)
3. Successful Bidder
4. Current Contrator

Clear Data